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INDIANA HEALTH COVERAGE PROGRAMS
PROVIDER REFERENCE MODULE
Member Eligibility
and Benefit Coverage
L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 0 9 P U B L I S H E D : M A Y 1 4 , 2 0 2 0 P O L I C I E S A N D P R O C E D U R E S A S O F A P R I L 1 , 2 0 1 9 V E R S I O N : 4 . 0
© Copyright 2020 DXC Technology Company. All rights reserved.
Library Reference Number: PROMOD00009 iii
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Revision History
Version Date Reason for Revisions Completed By
1.0 Policies and procedures as
of October 1, 2015
Published: July 19, 2016
New document FSSA and HPE
1.1 Policies and procedures as
of September 1, 2016
(CoreMMIS updates as of
February 13, 2017)
Published: June 20, 2017
Scheduled update FSSA and HPE
3.0 Policies and procedures as
of March 1, 2018
Published: October 2, 2018
Scheduled update FSSA and DXC
4.0 Policies and procedures as
of April 1, 2019
Published: May 14, 2020
Scheduled update:
Reorganized and edited text as
needed for clarity
Added initial note box with
standard wording
Updated links to the IHCP
website
Removed HIP Employer Link and
PRTF Transition Waiver
references
Updated the IHCP Programs and
Benefit Plans section
Added note about IEDSS
replacing ICES in the Member
Identification section
Updated sample cards in the
Healthy Indiana Plan Member
Card section
Added a note about Hoosier
Healthwise logo update and
removed sample cards with the
old logo in the Hoosier
Healthwise Member Card section
Removed MCE Health Plan
Eligibility section
Added a note box about future
dates in the Verifying Eligibility
for a Specific Date of Service
section
Added the Eligibility Verification
on the Portal section and
subsections
FSSA and DXC
Member Eligibility and Benefit Coverage Revision History
iv Library Reference Number: PROMOD00005
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Version Date Reason for Revisions Completed By
Added a note about the
Emergency Services Only with
Pregnancy Services (Package B)
benefit plan to Section 2: Fee-for-
Service Programs and Benefits
Updated the list of eligible groups
in the Traditional Medicaid
section
Clarified in the HCBS and ESRD
Waiver Liability section when a
provider can bill a member for
amounts credited to liability
Added the Benefit Limits and
Waiver Liability section
Made clarifications to the
descriptions and notes in Table 2
– Medicare Savings Program
Coverage Categories
Updated the Eligibility
Verification for QMB-Also and
SLMB-Also Members with
Liability section
Updated the Emergency Services
Only – Package E section
Updated the Fee-for-Service
Benefit Options section
Replaced list of eligible provider
types with a reference to the
Provider Enrollment module in
the Primary Medical Providers
section
Clarified information about
psychiatric services in the
Self-Referral Services section
Updated the Healthy Indiana Plan
section and subsections
Updated the Hoosier Care
Connect section
Updated the Hoosier Healthwise
Package A section
Updated the Package C
Enrollment Process and Cost-
Sharing Requirements section
Updated Table 8 – Comparing
Hoosier Healthwise Benefit
Packages A and C
Updated the General
Requirements for Presumptive
Eligibility section
Revision History Member Eligibility and Benefit Coverage
Library Reference Number: PROMOD00005 v
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Version Date Reason for Revisions Completed By
Updated the Presumptive
Eligibility Aid Categories and
Benefit Plans section to reflect all
PE plans are now fee-for-service
Added the Portal Copayment
Response section
Added Section 6: Benefit Limit
Information
Updated the introduction to
Section 7: Retroactive Member
Eligibility
Added the Retroactive Eligibility
for Managed Care Members
section
Updated the Limited Retroactive
Eligibility for Hoosier Healthwise
Package C Members section
Updated the Provider
Responsibilities for Retroactive
Eligibility section
Updated the introductory text in
Section 8: Member Appeals
Library Reference Number: PROMOD00009 vii
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Table of Contents
Section 1: Member Eligibility Overview ....................................................................................... 1 IHCP Programs and Benefit Plans ............................................................................................. 1 Member Identification ................................................................................................................ 3
Hoosier Health Card ........................................................................................................... 3 Healthy Indiana Plan Member Card .................................................................................... 4 Hoosier Care Connect Member Card .................................................................................. 6 Hoosier Healthwise Member Card ...................................................................................... 7
Eligibility Verification System .................................................................................................. 7 Information Available through the EVS ............................................................................. 8 EVS Update Schedule ......................................................................................................... 9 Verifying Eligibility for a Specific Date of Service ............................................................ 9 Proof of Eligibility Verification .......................................................................................... 9 Eligibility Verification on the Portal ................................................................................. 10
Section 2: Fee-for-Service Programs and Benefits ..................................................................... 17 Traditional Medicaid ................................................................................................................ 18
Indiana Breast and Cervical Cancer Program ................................................................... 18 HCBS and ESRD Waiver Liability ................................................................................... 19
Medicare Savings Programs – QMB, SLMB, QI, QDWI ........................................................ 20 Eligibility Verification for QMB-Also and SLMB-Also Members with Liability ........... 23 Medicaid and the Medicare Prescription Drug Coverage Program................................... 23
Emergency Services Only – Package E ................................................................................... 24 Family Planning Eligibility Program ....................................................................................... 24 590 Program ............................................................................................................................. 26 Fee-for-Service Benefit Options .............................................................................................. 26
1915(c) HCBS Waiver Services ....................................................................................... 26 1915(i) State Plan HCBS Program Services ..................................................................... 27 Medicaid Rehabilitation Option Services ......................................................................... 28
Section 3: Managed Care Programs ............................................................................................ 29 Primary Medical Providers ...................................................................................................... 29 Self-Referral Services .............................................................................................................. 29 Carved-Out Services ................................................................................................................ 30 Excluded Services .................................................................................................................... 31 Healthy Indiana Plan ................................................................................................................ 31
Member Eligibility for HIP ............................................................................................... 33 Personal Wellness and Responsibility Account and Copayments .................................... 35 Covered Services .............................................................................................................. 36
Hoosier Care Connect .............................................................................................................. 37 Hoosier Healthwise .................................................................................................................. 38
Package A ......................................................................................................................... 39 Package C ......................................................................................................................... 40 Hoosier Healthwise Package Comparison ........................................................................ 43
Program of All-Inclusive Care for the Elderly ......................................................................... 55
Section 4: Special Programs and Processes ................................................................................. 57 Presumptive Eligibility ............................................................................................................ 57
Presumptive Eligibility Coverage Period .......................................................................... 57 General Requirements for Presumptive Eligibility ........................................................... 57 Presumptive Eligibility Aid Categories and Benefit Plans ............................................... 58 Presumptive Eligibility for Inmates .................................................................................. 59
Medical Review Team ............................................................................................................. 60 Right Choices Program ............................................................................................................ 61
Member Eligibility and Benefit Coverage Table of Contents
viii Library Reference Number: PROMOD00005
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Preadmission Screening and Resident Review ........................................................................ 62
Section 5: Member Copayment Policies ...................................................................................... 63 Overview .................................................................................................................................. 63 Copayment Limitations and Exemptions ................................................................................. 63 Service-Specific Copayment Policies ...................................................................................... 64
Transportation Services .................................................................................................... 65 Pharmacy Services ............................................................................................................ 65 Nonemergency Services Rendered in the Emergency Department ................................... 65
Portal Copayment Response .................................................................................................... 66
Section 6: Benefit Limit Information ........................................................................................... 69 Checking Benefit Limits on the EVS ....................................................................................... 69 Checking Benefit Limits via Written Correspondence ............................................................ 72 Calendar-Year Versus 12-Month Monitoring Cycle ................................................................ 73 Billing Members for Services that Exceed Benefit Limits ....................................................... 74
Section 7: Retroactive Member Eligibility .................................................................................. 75 Retroactive Eligibility for Managed Care Members ................................................................ 75 Limited Retroactive Eligibility for Hoosier Healthwise Package C Members ......................... 75 Provider Responsibilities for Retroactive Eligibility ............................................................... 76
Section 8: Member Appeals .......................................................................................................... 77
Library Reference Number: PROMOD00009 1
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Section 1: Member Eligibility Overview
Note: For updates to the information in this module, see IHCP Banner Pages and Bulletins
at in.gov/medicaid/providers.
The Family and Social Services Administration (FSSA) offers a number of different programs and services
under the Indiana Health Coverage Programs (IHCP) umbrella. Program and service options are available
to Hoosiers based on established eligibility criteria.
Providers should advise people interested in applying for IHCP benefits to submit an Indiana Application
for Health Coverage using any of the following options:
Apply online through the FSSA Benefits Portal.
Apply by telephone by calling the Division of Family Resources (DFR) call center at 1-800-403-0864.
Apply in person at their local DFR office.
Member eligibility for the 590 Program is initiated by the institution where the member resides. The FSSA
provides general information about program eligibility and application on the IHCP member website at
in.gov/medicaid/members.
The IHCP reimburses participating providers for necessary and reasonable medical services provided
to individuals who are enrolled in the IHCP and who are eligible for the benefit at the time service is
provided. The member is free to select the provider of services, unless the member is restricted to a specific
provider through the Right Choices Program (RCP) or through a managed care program.
IHCP Programs and Benefit Plans
Generally, IHCP members receive benefits under either the fee-for-service (FFS) delivery system or the
managed care delivery system, depending on which program they are enrolled in. However, certain services
and benefit options cross over delivery systems and are delivered as FFS for all eligible members,
including members enrolled under a managed care program.
IHCP programs and services are delivered as follows:
FFS programs and services are delivered by enrolled IHCP providers and reimbursed directly
through the IHCP fiscal agent, DXC Technology, or by the FFS pharmacy benefit manager,
OptumRx. See the Fee-for-Service Programs and Benefits section of this module for information
about FFS programs as well as certain benefit options that are delivered as FFS regardless of
whether the member is enrolled in an FFS or managed care program.
Managed care programs and services are delivered by enrolled IHCP providers that participate in
managed care networks. Services are reimbursed by managed care entities (MCEs) contracted by the
State to manage the care for their members, or by subcontractors of the MCEs. See the Managed
Care Programs section of this module for information about the IHCP managed care programs and
benefit plans.
See the Special Programs and Processes section of this module for information about special programs and
processes, including coverage for presumptively eligible individuals as well as information about the Right
Choices Program.
Table 1 lists the specific IHCP benefit plans associated with each program, benefit option, or special process.
Member Eligibility and Benefit Coverage Section 1: Member Eligibility Overview
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Policies and procedures as of April 1, 2019
Version: 4.0
Table 1 – IHCP Programs and Associated Benefit Plans
Fee-for-Service Program Benefit Plan Name
Traditional Medicaid Full Medicaid*
* With no managed care program assignment (Fee-for-service
plus nonemergency medical transportation [NEMT])
Package A – Standard Plan*
* With no managed care program assignment (Fee-for-service
plus NEMT)
Medicare Savings Programs Qualified Disabled Working Individual
Qualified Individual
Qualified Medicare Beneficiary
Specified Low Income Medicare Beneficiary
Emergency Services Only** Package E – Emergency Services Only
Family Planning Eligibility Program Family Planning Eligibility Program
590 Program 590 Program
Managed Care Program Benefit Plan Name
Healthy Indiana Plan HIP Basic
HIP Plus
HIP State Plan Basic
HIP State Plan Plus
HIP State Plan Plus Copay
HIP Maternity
Hoosier Care Connect Full Medicaid*
* With Hoosier Care Connect managed care program assignment
Package A – Standard Plan*
* With Hoosier Care Connect managed care program assignment
Hoosier Healthwise Package A – Standard Plan*
* With Hoosier Healthwise managed care program assignment
Package C – Children’s Health Plan (SCHIP)
Program of All-Inclusive Care for the
Elderly (PACE)
Program of All-Inclusive Care for the Elderly
Benefit Option (Fee-for-Service) Benefit Plan Name
1915(i) State Plan Home and Community-
Based Services (HCBS)
Adult Mental Health Habilitation
Children’s Mental Health Wraparound
Behavioral & Primary Healthcare Coordination
1915(c) HCBS Waiver Aged and Disabled HCBS Waiver
Community Integration and Habilitation HCBS Waiver
Family Supports HCBS Waiver
Traumatic Brain Injury HCBS Waiver
Money Follows the Person (MFP)
Demonstration Grant
MFP Traumatic Brain Injury
MFP Demonstration Grant HCBS Waiver [Aged and Disabled]
Medicaid Rehabilitation Option (MRO) Medicaid Rehabilitation Option
Section 1: Member Eligibility Overview Member Eligibility and Benefit Coverage
Library Reference Number: PROMOD00005 3
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Special Program or Process Benefit Plan Name
Presumptive Eligibility Presumptive Eligibility – Adult
Presumptive Eligibility Family Planning Services Only
Presumptive Eligibility – Package A Standard Plan
Presumptive Eligibility for Pregnant Women
Medicaid Inpatient Hospital Services Only
[PE for Inmates]
Medical Review Team (MRT) Medical Review Team
Preadmission Screening and Resident
Review (PASRR)
PASRR Individuals with Intellectual Disability
PASRR Mental Illness (MI)
Notes:
* Full Medicaid and Package A – Standard Plan offer the same level of benefits.
** Effective November 30, 2019, the IHCP added a new FFS Emergency Services Only (ESO) benefit plan
called ESO Coverage with Pregnancy Coverage (also referred to as Package B).
Member Identification
Each IHCP member is issued a 12-digit identification number that is referred to as the Member ID (also
known as RID). The Member ID is assigned by the FSSA DFR through the automated Indiana Client
Eligibility System (ICES). Each member also receives a member identification card. The type of card
received depends on the IHCP program in which the member is enrolled.
Note: The Indiana Eligibility Determination and Services System (IEDSS) is replacing the
ICES in a phased rollout process. The FSSA Benefits Portal will appear the same to
members and authorized representatives. However, members with fully open cases
will be receiving a new case number when their cases convert through IEDSS.
Providers will not notice a change on the eligibility options used to verify member
eligibility, described in the Eligibility Verification System section.
Hoosier Health Card
The IHCP member identification card, called the Hoosier Health Card, is used to identify enrollment in
IHCP FFS programs, including Traditional Medicaid, Emergency Services Only, Medicare Savings
Programs, and the Family Planning Eligibility Program. Each family member covered by the IHCP
receives an ID card specific to that member. The front of the Hoosier Health Card contains the following
information about the member (as shown in Figure 1):
IHCP Member ID
Name
Date of birth
Gender
Member Eligibility and Benefit Coverage Section 1: Member Eligibility Overview
4 Library Reference Number: PROMOD00005
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Figure 1 – Hoosier Health Card
Hoosier Health Cards are issued upon program enrollment. After the DFR determines eligibility, cards
are then generated and mailed within 5 business days of the action updating the IHCP Core Medicaid
Management Information System (CoreMMIS). The member must allow 5 business days plus mailing time
to receive the card. A letter to inform the member of eligibility status is system-generated within 24 hours
of eligibility determination.
The card is a permanent plastic identification card the member is expected to retain for his or her lifetime.
Members should retain their cards even if eligibility lapses, in case eligibility is reinstated at a later date.
Members may contact their local DFR county office or call toll-free 1-800-403-0864 to request a
replacement Hoosier Health Card.
Cards are not available at the local DFR county offices. Providers may photocopy cards.
Healthy Indiana Plan Member Card
HIP members receive member ID cards from their individual MCEs: Anthem, CareSource, Managed
Health Services (MHS), or MDwise. Examples of HIP cards are provided in Figures 2 through 6. Member
identification numbers are located in the indicated areas on the HIP cards shown in the figures.
Figure 2 – Sample Anthem HIP Member Card with Dental and Vision
Section 1: Member Eligibility Overview Member Eligibility and Benefit Coverage
Library Reference Number: PROMOD00005 5
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Figure 3 – Sample Anthem HIP Member Card without Dental and Vision
Figure 4 – Sample MHS HIP Member Card
Figure 5 – Sample MDwise HIP Member Card
Figure 6 – Sample CareSource HIP Member Card
Member Eligibility and Benefit Coverage Section 1: Member Eligibility Overview
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Policies and procedures as of April 1, 2019
Version: 4.0
Hoosier Care Connect Member Card
Hoosier Care Connect members receive member ID cards from their individual MCEs: Anthem or MHS.
Examples of Hoosier Healthwise member cards are provided in Figures 7 and 8. Member identification
numbers are located in the indicated areas.
Figure 7 – Sample Anthem Hoosier Care Connect Member Card
Figure 8 – Sample MHS Hoosier Care Connect Member Card
Section 1: Member Eligibility Overview Member Eligibility and Benefit Coverage
Library Reference Number: PROMOD00005 7
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Hoosier Healthwise Member Card
Hoosier Healthwise members receive member ID cards from their individual MCEs: Anthem, CareSource,
MHS, and MDwise.
Note: Hoosier Healthwise updated its brand logo in April 2020. Samples from each MCE
should be included in the next version of this module. Figure 9 provides an example
of what the new cards might look like, although there will be variations depending on
the MCE.
Figure 9 – Sample Hoosier Healthwise Member Card
Eligibility Verification System
Providers are required to verify member eligibility on the date of service. Providers that fail to verify
eligibility are at risk of claims being denied due to member ineligibility or coverage limitations. Viewing a
member ID card alone does not ensure member eligibility.
If the member is not eligible on the date of service, the member can be billed for services. However, it is
important to remember that, if retroactive eligibility is later established, the provider must bill the IHCP
and refund any payment that the member made to the provider.
Providers can verify member eligibility by using one of the following Eligibility Verification System
(EVS) options:
Provider Healthcare Portal (Portal) – See the Eligibility Verification on the Portal section for
instructions.
Approved vendor software for the 270/271 batch or interactive eligibility benefit transactions – See
the Electronic Data Interchange module for details.
Interactive Voice Response (IVR) system at 1-800-457-4584 – See the Interactive Voice Response
System module for instructions. (Customer Assistance representatives do not provide eligibility
verification information.)
Providers can use information from a member’s health card to access eligibility information on the EVS. If
a member does not have a member ID card at the time of service, a provider can still verify eligibility if the
provider has one of the following:
The member’s IHCP Member ID
The member’s Social Security number and date of birth
The member’s first and last name and date of birth
Member Eligibility and Benefit Coverage Section 1: Member Eligibility Overview
8 Library Reference Number: PROMOD00005
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Information Available through the EVS
It is important that providers verify member eligibility on the date of service. If a provider fails to verify
eligibility on the date of service, the provider risks claim denial. Claim denial could result if the member
was not eligible on the date of service, or if the service provided was outside the member’s scope of
coverage. Most claim denials are due to missing or incorrect information that should have been verified
through one of the EVS options.
Before rendering services, providers should always check member eligibility to determine the following:
Whether the individual has IHCP coverage on the date of service
What type of IHCP coverage the member has on the date of service (see Table 1 for a list of benefit
plans associated with the various IHCP programs)
Whether the member has other insurance coverage (known as third-party liability [TPL]) that takes
precedence over the IHCP coverage
Whether the member has a copayment responsibility for certain services
Whether a member is enrolled through a managed care program (such as HIP, Hoosier Care
Connect, or Hoosier Healthwise) and, if so, to which MCE and PMP the member is assigned
(name and telephone number) and the MCE delivery network associated with the member’s PMP,
if applicable
Note: If the EVS indicates that the member is enrolled in a managed care program,
the MCE identified must be contacted for more specific program information.
If the EVS indicates that the member has a PMP, the physician identified must be
contacted to determine whether a referral is needed. If the member has been assigned
to multiple PMPs during the time period of the eligibility request, the eligibility
response includes each PMP and the PMP-MCE information with the date segments
that the member was assigned to the PMP.
Whether the member is restricted to a designated pharmacy, hospital, and physician (PMP) through
the Right Choices Program
What level of care (LOC) is assigned for long-term care (LTC) or hospice members as well as
whether a member who resides in an LTC facility has a patient liability and, if so, how much
liability to collect from the member
Whether the member has a waiver liability
What services are authorized under the member’s Medicaid Rehabilitation Option (MRO) or 1915(i)
State Plan Home and Community-Based Services (HCBS) benefit (for applicable provider types
only)
Whether member benefit limitations have been reached
Note: Benefit limit information provided by the EVS reflects only claims that are processed
in CoreMMIS. Claims paid by MCEs are not reflected in the EVS benefit limit
information.
Section 1: Member Eligibility Overview Member Eligibility and Benefit Coverage
Library Reference Number: PROMOD00005 9
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
EVS Update Schedule
The DFR authorizes and initiates actions that affect member eligibility. The EVS is updated daily with
member eligibility information transmitted from the ICES. The timing of the process (with the exception of
Friday’s activity) is as follows:
1. Information from ICES is downloaded from all counties daily after the close of business.
2. This file is passed electronically to CoreMMIS between midnight and 5 a.m. the next day.
3. CoreMMIS completes file processing by 9 a.m. the same day it receives the file.
4. The EVS is updated around 11 p.m. the day the file was processed. In the case of Friday’s activity,
the EVS is not updated until 11 p.m. Sunday.
The entire process takes 2 days to complete, with the exception of Friday’s activity, which takes 3 days to
complete. For example, if a DFR worker makes changes on Monday and the changes are transmitted to
CoreMMIS Tuesday morning, between midnight and 5 a.m., CoreMMIS completes processing of
Monday’s file by 9 a.m. Tuesday. The EVS is updated by 11 p.m. Tuesday.
Verifying Eligibility for a Specific Date of Service
All eligibility verification options can be used to verify the eligibility status of a member for dates of
service up to 7 years in the past. Eligibility inquiries are limited to a 1-calendar-month date span.
Note: Eligibility cannot be verified for future dates, because eligibility cannot be
guaranteed before the date of service.
Providers may verify eligibility for members for any date of service that is within the provider’s IHCP
enrollment period. However, the EVS restricts providers from accessing member eligibility information for
dates of service on which the provider was not actively enrolled in the IHCP. If providers enter a date span,
each day in the date span must be within the provider’s enrollment period. For example, if the provider is
enrolled in the IHCP from 11/1/15 to 5/7/19, and an eligibility inquiry is entered for a date span of 5/1/19 to
5/10/19, the dates of 5/8, 5/9, and 5/10 all fall outside the provider’s enrollment period. Even though there
are some days that fall within the date range, because there are some days that fall outside, the inquiry on
eligibility verification will not be allowed.
Proof of Eligibility Verification
Providers must retain proof that member eligibility was verified. For verification conducted via the IVR
system, providers must document the verification number provided by the IVR system and record it for
future reference. In the event that a discrepancy exists between the verification information obtained on the
date of service and eligibility information on file, the verification number can be used to resolve the matter
for claim processing.
The Portal contains a time-and-date stamp used for proof of timely eligibility verification. If a provider is
required to prove timely eligibility verification, the provider must send a screen print from the Portal to the
Written Correspondence Unit with a completed claim. The Claim Submission and Processing module
provides additional information about written correspondence policies.
Member Eligibility and Benefit Coverage Section 1: Member Eligibility Overview
10 Library Reference Number: PROMOD00005
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Eligibility Verification on the Portal
To verify eligibility online via the Portal, users must first establish a registered account on the Portal, as
described in the Provider Healthcare Portal module.
Use the following steps to verify eligibility on the Portal:
1. Log in to the Provider Healthcare Portal, accessible from the home page at
in.gov/medicaid/providers.
2. Click the Eligibility tab on the Portal menu bar to access the Eligibility Verification Request panel.
3. Enter one of the following:
– Member ID
– Member’s Social Security number (SSN) and birth date
– Member’s last name, first name, and birth date
4. Enter the date, or date range, for which eligibility is being checked:
– The Effective From field is always required. If a date is not entered in this field, the Portal
defaults this field to the current date. This field only accepts current and previous dates.
– The Effective To field is optional. If a date is entered, it must be on or after the date in the
Effective From field and must be within the same calendar month as that date. If a date is not
entered in this field, it will default to the date in the Effective From field.
5. Click Submit to determine the member eligibility for the specified date or date range.
Figure 10 – Eligibility Verification Request Panel
6. The Portal displays results of the search:
– If the search criteria do not match information in the Portal, a message appears above the search
panel stating: “Error: Member not found; confirm and/or revise search criteria.” (See Figure 11.)
– If the Portal finds results for the search criteria entered, but the member does not have coverage
for the dates searched, the words “Not Eligible” appear in the coverage details for that member.
(See Figure 12.)
– If the Portal finds coverage for the dates entered, it lists the member’s benefit plans, as well as
additional information, in the Coverage Details panel. (See Figure 13.)
Figure 11 – Eligibility Verification Request – No Information Found
Section 1: Member Eligibility Overview Member Eligibility and Benefit Coverage
Library Reference Number: PROMOD00005 11
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Figure 12 – Eligibility Verification Request – No Coverage for Dates Searched
Figure 13 – Eligibility Verification Information
Note: For a claim to be considered for payment, the date of service must fall within an
effective date range.
7. Within the Coverage Details panel, all panels other than Benefit Details are initially collapsed. As
you expand (+) the panels, you are able view to more information. You can also select Expand All to
display all the information for all the panels. Only panels applicable to the member’s coverage are
displayed.
The following sections describe all possible panels returned with an eligibility verification request.
Member Eligibility and Benefit Coverage Section 1: Member Eligibility Overview
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Policies and procedures as of April 1, 2019
Version: 4.0
Benefit Details
The Benefit Details panel lists the member’s coverage, including benefit plan name and description, and
copayment amounts:
For more information about IHCP benefit plans, see Table 1 and the Fee-for-Service Programs and
Benefits, Managed Care Programs, and Special Programs and Processes sections.
For more information about copayments, see the Member Copayment Policies section.
Figure 14 – Benefit Details
Limit Details
The Limit Details panel lists certain service or dollar limits that may be applicable for a member. The panel
shows a description of the limit, the limit amount allowed, and the amount that is still remaining to the
member. The amount indicated as remaining is based on FFS paid claims. The actual amount remaining
may be different – for example, if a service has been rendered but the claim has not yet been paid. See
Section 6: Benefit Limit Information for more information.
Figure 15 – Limit Details
Section 1: Member Eligibility Overview Member Eligibility and Benefit Coverage
Library Reference Number: PROMOD00005 13
Published: May 14, 2020
Policies and procedures as of April 1, 2019
Version: 4.0
Managed Care Assignment Details
For members enrolled in a managed care program, such as HIP, Hoosier Care Connect, or Hoosier
Healthwise, the Managed Care Assignment Details identifies the member’s managed care program, PMP
name and telephone number, MCE name and telephone number, and delivery network associated with the
PMP, if a delivery network is applicable. The option to submit a Notification of Pregnancy (NOP) for
managed care members is also available from this panel; see the Obstetrical and Gynecological Services
module for details.
Figure 16 – Managed Care Assignment Details – Managed Care
For FFS members subject to brokerage requirements for nonemergency medical transportation (NEMT)
services, the Managed Care Assignment Details panel displays the name of the broker that must be used
to arrange the transportation. These members are still considered FFS for all other services; however,
scheduling and billing of the NEMT service must be done through the broker, as described in the
Transportation Services module.
Figure 17 – Managed Care Assignment Details – FFS with Brokered NEMT
Right Choices Program
The Right Choices Program panel lists the providers assigned to the Right Choices Program (RCP)
member. These providers are approved for a member to use for services. See the Right Choices Program
module for details.
Figure 18 – Right Choices Program
Note: Effective April 30, 2020, the IHCP is removing the hospital lock-in requirement from
the Right Choices Program. A primary lock-in hospital will no longer be required for
RCP members.
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Waiver Liability Details
The Waiver Liability Details panel shows the member’s Medicaid waiver liability obligation and the
remaining balance. The balance amount shown may not reflect claims not yet processed. Providers may bill
the member for the amount credited to liability after the claim is adjudicated. See the HCBS and ESRD
Waiver Liability section for details.
Figure 19 – Waiver Liability Details
Nursing Home/Hospice Level of Care
The Nursing Home/Hospice Level of Care panel displays level of care (LOC), eligibility dates, and the
member’s liability obligation for the effective coverage. See the Hospice Services and Long-Term Care
modules for more information.
Figure 20 – Nursing Home/Hospice Level of Care
Note: The Portal displays LOC information for FFS services only. To confirm hospice
benefits provided under a managed care program, providers must contact the
member’s MCE.
Detail Information
The Detail Information panel displays information for authorized Medicaid Rehabilitation Option (MRO)
and 1915(i) services. Note that only those users with the correct specialty for MRO or the 1915(i)
specialties can see this information. All other provider specialties cannot see this data.
For details about these programs, see the Medicaid Rehabilitation Option Services and 1915(i) State Plan
HCBS Program Services sections.
Figure 21 – Detail Information
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Other Insurance Details
The Other Insurance Details panel displays information about other coverage, in addition to IHCP benefits,
on file for the member. The information provided includes the carrier’s name (and Carrier ID), address, and
telephone number and the policyholder’s policy ID, group ID, name, and coverage type. For more
information about billing and reimbursement for members with other insurance, in addition IHCP coverage,
see the Third Party Liability module.
Figure 22 – Other Insurance Details
Note: Providers can update information about a member’s other insurance by using the
Portal’s Secure Correspondence link, with TPL Update selected as the category. See
the Provider Healthcare Portal module for details.
Demographic Details
The Demographic Details panel displays the address on file for the member.
Figure 23 – Demographic Details
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Section 2: Fee-for-Service Programs and Benefits
Indiana Health Coverage Programs (IHCP) members enrolled in programs delivered as fee-for-service
(FFS) are not enrolled with a managed care entity (MCE) and are not required to choose a primary medical
provider, unless they are assigned to the Right Choices Program. See the Introduction to the IHCP module
for detailed information about the FFS delivery system.
The programs associated with the FFS delivery system include:
Traditional Medicaid (identified in the IHCP Eligibility Verification System [EVS] as Full
Medicaid or Package A – Standard Plan coverage with no managed care details)
Medicare Savings Programs
– Qualified Medicare Beneficiary (QMB)
– Specified Low Income Medicare Beneficiary (SLMB)
– Qualified Individual (QI)
– Qualified Disabled Working Individual (QDWI)
Note: Members identified in the EVS as having both Qualified Medicare Beneficiary
coverage and also Full Medicaid or Package A coverage are known as QMB-Also.
Members identified as having both Specified Low Income Medicare Beneficiary
coverage and also Full Medicaid or Package A coverage are known as SLMB-Also.
Members who have only QMB coverage or only SLMB coverage (not in conjunction
with Full Medicaid or Package A) are known as QMB-Only or SLMB-Only. See the
Medicare Savings Programs – QMB, SLMB, QI, QDWI section for details.
Emergency Services Only (Package E)
Family Planning Eligibility Program
590 Program
Inpatient Hospital Services Only (for inmates)
Note: Effective November 30, 2019, the IHCP expanded the Emergency Services Only
(ESO) benefits for certain qualified immigrants identified as lawful permanent
residents. This new FFS benefit plan is called ESO Coverage with Pregnancy
Coverage, and may also be referred to as “Package B.” Package B covers prenatal
and postpartum services until 60 days after the pregnancy ends, in addition to all
services covered under Package E – Emergency Services Only.
See the Fee-for-Service Benefit Options section for information about additional service options that are
available on an FFS basis.
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Traditional Medicaid
The Traditional Medicaid program provides coverage for healthcare services rendered to individuals in the
following groups who meet eligibility criteria, such as specific income guidelines:
Persons in long-term care (LTC) facilities and other institutions, such as a nursing facility (NF) or
an intermediate care facility for individuals with intellectual disability (ICF/IID)
Persons eligible for Hoosier Healthwise who qualify for IHCP hospice benefits
Persons eligible for a Home and Community-Based Services (HCBS) waiver program, including
those with a waiver liability
Persons with end-stage renal disease (ESRD), including those with a waiver liability
Persons with both Medicare and Medicaid (dual eligibility)
Persons enrolled in the Breast or Cervical Cancer Treatment Program
Refugees who do not qualify for any other aid category
Children receiving adoption assistance
Wards of the State who opt out of Hoosier Care Connect
Foster children
Former foster children who turned 18 years of age while in foster care, are under age 26 (or under
age 21, if the foster care was outside of Indiana), and opt out of Hoosier Care Connect
Traditional Medicaid members are eligible for full coverage of Medicaid services, as described in the
Indiana State Plan. For details, see the Indiana State Plan, accessible from the Provider Reference
Materials page at in.gov/medicaid/providers.
In conjunction with Full Medicaid/Package A – Standard Plan benefits, Traditional Medicaid members
may, under certain circumstances, also be eligible for additional services, including 1915(c) HCBS waiver
services, 1915(i) State Plan HCBS program services, Medicaid Rehabilitation Option (MRO) services,
hospice services, and long-term care (LTC) services. These additional services are also delivered on an FFS
basis. Providers must consult the EVS to determine the member’s eligibility status and coverage details.
Indiana Breast and Cervical Cancer Program
Women diagnosed with breast or cervical cancer through the Indiana Breast and Cervical Cancer Program
(BCCP) of the Indiana State Department of Health (ISDH) are eligible for Traditional Medicaid coverage
during the course of treatment. These members are in the FFS delivery system only. To be eligible, a
woman must meet the following criteria:
Must be younger than 65 years old
Must not be eligible for another Medicaid category
Must not be covered by any other insurance that includes breast or cervical cancer treatment
Alternatively, a woman can receive coverage for treatment under the BCCP program if she was diagnosed
with breast or cervical cancer, but not screened through BCCP, if:
She is between the ages of 18 and 65.
She has income at or below 200% of the federal poverty level (FPL).
She is not eligible for Medicaid under any other category.
She has no health insurance that will cover her treatment.
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HCBS and ESRD Waiver Liability
Some individuals with income in excess of the Traditional Medicaid threshold, who are approved for HCBS
waiver services, are enrolled in Traditional Medicaid under the HCBS waiver liability provision. Waiver
liability is similar to a deductible. Medicaid provider responsibilities to members enrolled under the waiver
liability provision are published in Indiana Administrative Code 405 IAC 1-1-3.1. See the 1915(c) HCBS
Waiver Services section for information about special service options associated with HCBS waivers.
A similar waiver liability provision is available for some individuals approved for ESRD services. After
ending the spend-down program, the IHCP instituted a temporary program that grants Traditional Medicaid
eligibility to individuals with ESRD who were at risk of losing access to transplant services. To be eligible
for the Medicaid ESRD waiver liability provisions, an individual must:
Be eligible for Medicare
Not be in an institutional setting or on a waiver
Have income between 150% and 300% of the federal poverty level (FPL)
These individuals are subject to a monthly ESRD waiver liability. As authorized and approved by the
Centers for Medicare & Medicaid Services (CMS) for the temporary program, the liability amount is
calculated based on the previously used spend-down methodology.
Members with waiver liability must incur medical expenses in the amount of their excess income each
month before becoming eligible for Traditional Medicaid. It is the member’s responsibility to provide
nonclaim verification of incurred medical expenses to the Division of Family Resources (DFR). The
member becomes eligible at the beginning of the month, but payments are subject to reduction based on the
amount of waiver liability remaining for the month.
A provider may bill a member for the amount listed under PATIENT RESP on the Remittance Advice (RA).
With the exception of point-of-sale (POS) pharmacy claims, the IHCP does not require the member to pay the
provider until the member receives the liability summary notice. The IHCP notifies pharmacists of the amount
the member owes at the time the POS claim adjudicates so that the pharmacists can collect from the members at
the time of service. The IHCP permits the provider to bill a member after the second business day of the month
following the month the claim was adjudicated. The provider may not apply a more restrictive collection policy
to members with liability than to other patients or customers. If the provider has a general policy to refuse
service to a patient or customer with an unpaid bill, that policy may not be applied to a member with liability
before the member receives the liability summary notice. Providers must bill their usual and customary
charge to Medicaid. The maximum amount a provider can bill a member is the lesser of the liability obligation
remaining at the time the claim adjudicates or the usual and customary charge. For more information on waiver
billing information, see the Home and Community-Based Services Billing Guidelines module.
When a provider verifies member eligibility, if the member has a liability (either for HCBS waiver or
ESRD waiver), the EVS indicates the dollar amount of the remaining liability obligation for the month. On
the Provider Healthcare Portal (Portal), this liability amount is listed in the Waiver Liability Details panel;
see Figure 24. Providers can use the enhanced liability information to assist members with financial
planning for payment of the liability. Providers may not collect the liability obligation from the member at
the time of service. A provider may bill the member for the amount credited to liability after the provider
receives an RA showing that the claim has been adjudicated.
Figure 24 – Waiver Liability Details Panel in the Portal Eligibility Verification
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Benefit Limits and Waiver Liability
In general, denied services do not credit waiver liability. For example, a service that is not covered by
Medicaid under Indiana Administrative Code 405 IAC 5, and therefore denied by the IHCP, does not credit
waiver liability. However, a service that is denied because the member exceeds a benefit limit that cannot
be overridden with an approved prior authorization may credit waiver liability. See the Benefit Limit
Information section for more information about benefit limits.
Medicare Part D and Medicaid Waiver Liability
When a member qualifies for the Medicare Low-Income Subsidy (LIS), Medicare considers the member
qualified for the remainder of the calendar year. If the member qualifies for the Medicare LIS after the
first half of the current calendar year, Medicare considers the member qualified until the end of the next
calendar year. When qualified, Medicare Part D members are able to receive prescription drug coverage
from Medicare every month without waiting to meet the monthly Medicaid waiver liability.
Members must meet their monthly Medicaid waiver liability requirements prior to receiving Medicaid
benefits. Although members may not meet Medicaid waiver liability requirements as quickly, other medical
expenses, Medicare copayments, and Medicare-excluded drugs covered by the IHCP still count toward
the Medicaid waiver liability. Until Medicaid waiver liability is met, members are responsible for the
provider’s usual and customary charges (UCCs) for IHCP-covered drugs and other IHCP-covered health
services. Providers are not required to dispense IHCP-covered drugs if the member’s waiver liability has
not been met.
Medicare Savings Programs – QMB, SLMB, QI, QDWI
Federal law requires that state Medicaid programs pay Medicare coinsurance or copayment, deductibles,
and/or premiums for certain elderly and disabled individuals through a program called the Medicare
Savings Program. These individuals must meet the following eligibility criteria to receive assistance with
Medicare-related costs:
Entitled to Medicare
Low income
Few personal resources
Note: The terms coinsurance and copayment are interchangeable. When referred to in
outputs such as the IVR, Portal, Remittance Advice, and so forth, the term
“coinsurance” represents coinsurance and/or copayment.
Medicare Savings Program coverage falls into the following categories shown in Table 2.
For all QMBs, the IHCP pays the Medicare Part B premiums and Medicare Part A (as necessary), as well
as Medicare deductibles and coinsurance or copayment for Medicare-covered services when the Medicare
payment amount is less than the Medicaid allowed reimbursement amount. The member is never
responsible for the amount disallowed (paid at zero) when Medicare paid more than the Medicaid allowed
amount for the service.
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Table 2 – Medicare Savings Program Coverage Categories
Coverage Type Description of Coverage Notes
QMB-Only The member’s benefits are limited to
payment of:
The member’s Medicare Part A (if
not entitled to free Part A) and
Part B premiums
Deductibles and coinsurance or
copayment for Medicare-covered
services
IHCP claims for services not covered
by Medicare are denied as Medicaid
noncovered services. The member must
make payment in full for medical
supplies, equipment, and other services
not offered by Medicare, such as routine
physicals, dental care, hearing aids, and
eyeglasses.
When the EVS identifies a member
as having only Qualified Medicare
Beneficiary coverage (without also
having Full Medicaid or Package A –
Standard Plan coverage), the provider
should contact Medicare to confirm
medical coverage. Failure to confirm
coverage may result in a claim denial
because Medicare benefits may have
been discontinued or recently denied.
Providers should tell the member that the
service is not a Medicaid-covered service
for a member who has only QMB
coverage. If the member still wants the
service, the member is responsible for
payment. See the Provider Enrollment
module for additional information about
billing an IHCP member for noncovered
services.
QMB-Also
without waiver
liability
The member’s benefits include payment
of:
The member’s Medicare Part A (if
not entitled to free Part A) and
Part B premiums
Deductibles and coinsurance or
copayment on Medicare-covered
services
Traditional Medicaid benefits
(excluding prescription drug
coverage, as stated in the Medicaid
and the Medicare Prescription
Drug Coverage Program section)
throughout each month of eligibility
When the EVS identifies a member as
having Qualified Medicare Beneficiary
coverage and also Full Medicaid or
Package A – Standard Plan coverage,
claims for services covered by Medicare
may cross over to Medicaid for
additional payment consideration.
Medicaid claims for services not
covered by Medicare must be
submitted as regular Medicaid claims
and not as crossover claims.
QMB-Also
with waiver liability
The member’s benefits include payment
of:
The member’s Medicare Part A (if
not entitled to free Part A) and
Part B premiums
Deductibles and coinsurance or
copayment for Medicare-covered
services
Traditional Medicaid benefits
(excluding prescription drug
coverage, as stated in the Medicaid
and the Medicare Prescription
Drug Coverage Program section)
after the member’s monthly
liability is met
When the EVS identifies a member as
having Qualified Medicare Beneficiary
coverage and also Full Medicaid or
Package A – Standard Plan coverage,
but with an unmet waiver liability, claims
may process toward the member’s waiver
liability amount; however, until the
waiver liability is satisfied for the month,
the member’s benefits are limited to
payment of Medicare premium and
deductibles, coinsurance, or copayment
for Medicare-covered services.
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Coverage Type Description of Coverage Notes
SLMB-Only The member’s benefits are limited to
payment of the member’s Medicare
Part B premium only.
Providers should tell the member that the
service is not a Medicaid-covered service
for a member who has only SLMB
coverage.
When the EVS identifies a member as
having only Specified Low Income
Medicare Beneficiary coverage (without
also having Full Medicaid or Package A
– Standard Plan coverage), the provider
should contact Medicare to confirm
medical coverage. Failure to confirm
coverage may result in a claim denial
because Medicare benefits may have
been discontinued or recently denied.
If the member still wants the service,
the member is responsible for payment.
See the Provider Enrollment module for
additional information about billing
an IHCP member for noncovered
services.
SLMB-Also
without waiver
liability
The member’s benefits include payment
of:
The member’s Medicare Part B
premium
Traditional Medicaid benefits
(excluding prescription drug
coverage, as stated in the Medicaid
and the Medicare Prescription
Drug Coverage Program section)
throughout each month of eligibility
When the EVS identifies a member as
having Specified Low Income Medicare
Beneficiary coverage and also Full
Medicaid or Package A – Standard Plan
coverage, claims for services covered by
Medicare may cross over to Medicaid for
additional payment consideration.
Medicaid claims for services not
covered by Medicare must be
submitted as regular Medicaid claims
and not as crossover claims.
SLMB-Also
with waiver liability
The member’s benefits include payment
of:
The member’s Medicare Part B
premium
Traditional Medicaid benefits
(excluding prescription drug
coverage, as stated in the Medicaid
and the Medicare Prescription
Drug Coverage Program section)
after the member’s monthly
liability is met
When the EVS identifies a member as
having Specified Low Income Medicare
Beneficiary coverage and also Full
Medicaid or Package A – Standard Plan
coverage, but with an unmet waiver
liability, claims may process toward the
member’s waiver liability amount;
however, until the waiver liability is
satisfied for the month, the member’s
benefits are limited to payment of the
Medicare Part B premium.
QI The member’s benefit is limited to
payment of the member’s Medicare
Part B premium only.
The EVS identifies this coverage as
Qualified Individual.
QDWI The member’s benefit is limited to
payment of the member’s Medicare
Part A premium only.
The EVS identifies this coverage as
Qualified Disabled Working Individual.
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Eligibility Verification for QMB-Also and SLMB-Also Members with Liability
The EVS options (Portal, IVR system, or 270/271 transaction) return the following eligibility information
for QMB-Also and SLMB-Also members with a waiver liability:
That the member is QMB-Also or SLMB-Also:
– For QMB-Also members, the EVS indicates both Qualified Medicare Beneficiary coverage and
also Full Medicaid or Package A coverage
– For SLMB-Also members, the EVS indicates both Specified Low Income Medicare Beneficiary
coverage and also Full Medicaid or Package A coverage
That the member has liability
Whether or not the member’s liability has been met for the month
If the member’s liability has not been met, the amount that remains for the month
The EVS maintains all historical waiver liability information. The EVS reports the dollar amount of the
remaining liability obligation for the month.
Services rendered up to the cost of the member liability are the responsibility of the member to pay to the
rendering provider, and it is the responsibility of the provider to collect the liability payment from the
member. Providers may not collect the liability obligation from the member until the claim is adjudicated
showing that the member liability has been applied to the provider claim.
Costs for rendered services beyond the liability are paid by the IHCP, and medically necessary services
beyond the cost of the liability must still be provided to the member.
Medicaid and the Medicare Prescription Drug Coverage Program
With implementation of the Medicare Modernization Act (MMA) and Medicare Part D prescription drug
coverage program (Medicare Part D), the IHCP can no longer pay for Medicare-covered prescription drugs.
Medicaid covers excluded Medicare Part D drugs that are listed on the IHCP Over-the-Counter Drug
Formulary and barbiturates (when used for medically accepted indications other than epilepsy, cancer, or
chronic mental health disorders; for example, the combination product butalbital/aspirin/caffeine, indicated
for headaches). Enrollment in Medicare Part D prescription drug coverage is voluntary.
Medicaid members who receive full Medicaid benefits and who are enrolled in Medicare Part A or Part B
do not have coverage for Medicare Part D-covered drugs unless they join, or are auto-enrolled by Medicare
into, a Medicare prescription drug plan (PDP). Medicaid does not pay for Medicare Part D-covered drugs
for people who are enrolled in Medicare or who decline the Medicare Part D coverage or disenroll from the
Medicare PDP.
Note: The IHCP does not cover compounded drug products containing a Medicare Part D-
covered drug product for dually eligible members.
The Medicare LIS, also known as “Extra Help,” is a federal subsidy provided by Medicare that helps
members pay for their Medicare PDP premiums, copays, and deductibles. Members need to apply for this
assistance program through Social Security at 1-800-722-1213 or access help online at the Social Security
website at socialsecurity.gov. If the member chooses a Medicare PDP with higher premiums than the
amount that Medicare will subsidize, he or she will have to pay the difference. Assistance can also be
obtained through any of the local Social Security offices in the member’s area.
Questions about Medicare prescription drug coverage can be directed to Medicare at 1-800-Medicare
(1-800-633-4227), TTY users 1-877-486-2048, or the Medicare website at medicare.gov. Members
can contact Medicare or State Health Insurance Assistance Program (SHIP) at 1-800-452-4800
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(1-866-846-0139 for TTY users) for help choosing a Medicare prescription drug plan or applying for the
“Extra Help.”
Emergency Services Only – Package E
Emergency Services Only (Package E) is for individuals who are otherwise eligible for Medicaid, but who
may not meet citizenship or immigration-status requirements for the program. Health coverage under
Package E is limited to treatment for medical emergency conditions. The Omnibus Budget Reconciliation
Act of 1986 (OBRA) defines an emergency medical condition as follows:
A medical condition of sufficient severity (including severe pain) that the absence of medical
attention could result in placing the member’s health in serious jeopardy, serious impairment of
bodily functions, or serious dysfunction of any organ or part
In the case of pregnant women eligible for coverage under Package E, labor and delivery services are also
considered emergency medical conditions.
Note: Effective November 30, 2019, the IHCP provides ESO Coverage with Pregnancy
Coverage (Package B) benefits for women who are lawful permanent residents. In
addition to all services covered under Package E, Package B provides prenatal and
postpartum services until 60 days after the pregnancy ends.
Children born in the United States to Package E members are eligible for full IHCP coverage upon
determination of eligibility through the DFR. (Outreach locations can screen for eligibility using
established guidelines; however, the final eligibility determination is made through DFR.) Children who are
not born in the United States are eligible only under Package E, unless the child is a current U.S. citizen, a
qualified alien, or a lawful permanent resident who has resided in the United States for 5 years or longer.
These children are only eligible for emergency coverage, and are not covered under the Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) program.
Package E members are in the FFS delivery system only. For billing instructions for Package E claims, see
the Claim Submission and Processing module.
Family Planning Eligibility Program
The Family Planning Eligibility Program provides only family planning services to qualifying men and
women, per Indiana Code IC 12-15-46 Medicaid Waivers and State Plan Amendments.
The Family Planning aid category includes men and women of any age who:
Do not qualify for any other category of Medicaid
Are not pregnant
Have not had a hysterectomy or sterilization
Have income that is at or below 141% of the federal poverty level
Are U.S. citizens, certain lawful permanent residents, or certain qualified documented aliens
Services rendered to members in the Family Planning Eligibility Program are reimbursed through the FFS
delivery system. Providers must verify eligibility before rendering services.
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The Family Planning Eligibility Program provides services and supplies to men and women for the primary
purpose of preventing or delaying pregnancy. Services covered under the Family Planning Eligibility
Program include:
Annual family planning visits, including health education and counseling necessary to understand
and make informed choices about contraceptive methods
Limited history and physical examinations
Laboratory tests, if medically indicated as part of the decision-making process regarding
contraceptive methods
Cytology (Pap tests) and cervical cancer screening, including high-risk human papillomavirus (HPV)
DNA testing, within the parameters described in the Obstetrical and Gynecological Services module
Follow-up care for complications associated with contraceptive methods issued by the family
planning provider
Food and Drug Administration (FDA)-approved oral contraceptives and contraceptive devices and
supplies, including emergency contraceptives
Initial diagnosis and treatment of sexually transmitted diseases (STDs) and sexually transmitted
infections (STIs), if medically indicated, including the provision of FDA-approved anti-infective
agents
Screening, testing, counseling, and referral of members at risk for human immunodeficiency virus
(HIV), within the parameters described in the Laboratory Services module
Tubal ligations
Hysteroscopic sterilization with an implant device
Vasectomies
IHCP reimbursement is available for Family Planning Eligibility Program-covered services rendered by
IHCP-enrolled providers, including but not limited to physicians, certified nurse midwives, family planning
clinics, and hospitals. Family Planning Eligibility Program services may be self-referred.
Services not covered under the Family Planning Eligibility Program include:
Abortions
Any drug or device intended to terminate fertilization
Artificial insemination
In vitro fertilization (IVF)
Fertility counseling
Fertility treatment
Fertility drugs
Inpatient hospital stays
Reversal of tubal ligation and vasectomies
Treatment for any chronic condition, including STDs and STIs that have advanced to a chronic
condition
Emergency room services
Services unrelated to family planning
For more information, see the Family Planning Eligibility Program module.
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590 Program
The 590 Program provides coverage for certain healthcare services provided to members 21 through 64
years of age who are residents of state-owned facilities. These facilities operate under the direction of the
Family and Social Services Administration (FSSA) Division of Mental Health and Addiction (DMHA) and
the Indiana State Department of Health (ISDH). Incarcerated individuals residing in Department of
Correction (DOC) facilities are not covered by the 590 Program.
The 590 Program is part of the fee-for-service delivery system. Members enrolled in the 590 Program are
eligible for the full array of benefits covered by the IHCP, with the exception of transportation services
(which are provided by facility). Coverage is limited to services performed outside the 590 Program facility
and to claims over $150 dollars. Only 590-enrolled providers can render services to 590 Program members.
For more information about program eligibility, coverage, and reimbursement, see the 590 Program module.
Fee-for-Service Benefit Options
Members meeting certain eligibility criteria may be eligible for services in addition to their primary benefit
plan. The following additional services are delivered and reimbursed through the FFS delivery system:
1915(c) Home and Community-Based Services (HCBS) waiver services – Certified individuals may
receive home and community-based services under a Medicaid waiver, in conjunction with
Traditional Medicaid benefits. (For some HCBS waiver services, Money Follows the Person [MFP]
demonstration grant services are available as a precursor to HCBS waiver eligibility.)
1915(i) State Plan HCBS program services – Certified individuals may receive designated home and
community-based nonwaiver services in conjunction with Traditional Medicaid, Hoosier Care
Connect, or Hoosier Healthwise benefits. (Behavioral and Primary Healthcare Coordination [BPHC]
services may also be delivered in conjunction with HIP State Plan and HIP Maternity benefits.)
MRO services – Certified individuals may receive MRO services in conjunction with Traditional
Medicaid, HIP State Plan, HIP Maternity, Hoosier Care Connect, or Hoosier Healthwise benefits.
Hospice services –Members enrolled in the Hoosier Healthwise managed care program may be
required to transition to Traditional Medicaid (under the FFS delivery system) to receive coverage
of in-home and/or institutional hospice services. (For all other managed care programs, hospice
services are covered within the managed care delivery system.) See the Hospice Services module for
details.
Long-term care – Members enrolled in a managed care program may be required to transition to
Traditional Medicaid (under the FFS delivery system) to receive coverage of long-term care
services. See the Long-Term Care module for details.
1915(c) HCBS Waiver Services
HCBS waivers cover a variety of home and community-based services not otherwise reimbursed by the
IHCP. HCBS waivers are available to those IHCP-eligible members who require the level-of-care (LOC)
services provided in a nursing facility, hospital, or ICF/IID, but choose to remain in the home.
Eligibility for all HCBS waivers requires the following:
The member must meet IHCP eligibility guidelines for Traditional Medicaid.
The member would require institutionalization in the absence of the waiver or other home-based
services.
If the member is enrolled in managed care, the member must be disenrolled from managed care and
enrolled in Traditional Medicaid to receive authorized HCBS waiver services.
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Members served under an HCBS waiver are ineligible for services under any other waiver. The HCBS
waivers are not entitlement programs and can serve only a limited number of members.
Indiana offers four HCBS waivers that target specific groups:
See the Division of Aging Home and Community-Based Services Waivers module for information
about the following two waivers for individuals who meet nursing facility (NF) level of care:
– Aged and Disabled Waiver
– Traumatic Brain Injury Waiver
See the Division of Disability and Rehabilitative Services Home and Community-Based Services
Waivers module for information about the following two waivers for individuals who meet ICF/IID
level of care:
– Community Integration and Habilitation Waiver
– Family Supports Waiver
HCBS waiver services allow members to live in a community setting and avoid institutional placement.
To be eligible for any waiver program, an individual must meet both Medicaid guidelines and waiver
eligibility guidelines.
Note: The Division of Aging also administers the Money Follows the Person (MFP)
program, which is funded through a federal grant from the CMS. Indiana’s MFP
program is specifically designed as a transition program to assist individuals who
live in qualifying institutions to move safely into the community and to ensure a safe
adjustment to community living. MFP serves eligible members for up to 365 days,
until they transition into the 1915(c) HCBS waiver that the grant is mirrored after:
Traumatic Brain Injury (TBI) or Aged and Disabled (A&D). All potential MFP
demonstration grant recipients must be enrolled in the IHCP Traditional Medicaid
program. For more information about the MFP program, see the Money Follows the
Person page at in.gov/fssa.
1915(i) State Plan HCBS Program Services
Section 1915(i) of the Social Security Act (SSA) gives states the option to offer a wide range of home and
community-based services to members through state Medicaid plans. Using this option, states can offer
services and supports to a target group of individuals, including individuals with serious mental illness,
emotional disturbance, and substance use disorders to help them remain in the community. Eligible
individuals may receive authorized services in conjunction with Traditional Medicaid, HIP State Plan,
Hoosier Care Connect, or Hoosier Healthwise benefits.
Indiana administers the following 1915(i) State Plan HCBS programs through the FSSA DMHA:
Adult Mental Health and Habilitation (AMHH) – See the Division of Mental Health and Addiction
Adult Mental Health and Habilitation Services module.
Behavioral and Primary Healthcare Coordination (BPHC) – See the Division of Mental Health and
Addiction Behavioral and Primary Healthcare Coordination Services module.
Child Mental Health Wraparound (CMHW) – See the Division of Mental Health and Addiction
Child Mental Health Wraparound Services module.
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Medicaid Rehabilitation Option Services
The IHCP reimburses for authorized Medicaid Rehabilitation Option (MRO) services for members with
mental illness when the provider for those services is an enrolled mental health center that meets applicable
federal, state, and local laws concerning the operation of community mental health centers (CMHCs). MRO
services include community-based mental healthcare for individuals with serious mental illness, youth with
serious emotional disturbance, and individuals with substance use disorders.
MRO services may include clinical attention in the member’s home, workplace, mental health facility,
emergency department, or wherever needed. A qualified mental health professional, as outlined in
405 IAC 5-21.5-1(c), must render these services.
For more information about MRO services, see the Medicaid Rehabilitation Option Services module.
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Section 3: Managed Care Programs
The State has mandated a managed care delivery system for Indiana Health Coverage Programs (IHCP)
members enrolled in the Healthy Indiana Plan (HIP), Hoosier Care Connect, or Hoosier Healthwise. In
each program, members are assigned to a managed care entity (MCE). Each MCE maintains its own
provider and member services units.
Member enrollment in managed care is effective on the 1st or 15th calendar day of a month, with some
exceptions, particularly for newborns born to MCE members. Managed care enrollment may be confirmed
by any of the Eligibility Verification System (EVS) options described in the Eligibility Verification System
section.
A member-requested change from one MCE to another is effective on the first day of the month. MCE
changes are completed by the enrollment broker during a member’s Open Enrollment period or as a just
cause.
Primary Medical Providers
As part of the managed care enrollment process, MCEs are responsible for assisting members with
selection of a primary medical provider (PMP). See the Healthy Indiana Plan, Hoosier Care Connect,
and Hoosier Healthwise Provider Enrollment section of the Provider Enrollment module for a list of
IHCP provider specialties that are eligible to enroll as a PMP.
Self-Referral Services Most services in managed care require referral from a PMP. Self-referral services are an exception. The
MCE reimburses any IHCP-enrolled providers for the following self-referral services unless other
parameters are indicated:
Chiropractic services rendered by a licensed chiropractor within chiropractic scope of practice
Podiatry services rendered by a licensed podiatrist or physician
Eye care services (except surgical services) rendered by a licensed optometrist or physician
Routine dental services rendered by a licensed dental provider within the MCE’s network
Diabetes self-management training (DSMT) services
Immunizations
Family planning services
Emergency services, as defined in Indiana Code IC 12-15-12-0.3 and IC 12-15-12-0.5
(Note: Services may be rendered by any qualified provider, but for non-IHCP-enrolled providers,
retroactive enrollment is required to facilitate payment.)
Urgent care services
Psychiatric services rendered by any IHCP-enrolled provider licensed to provide psychiatric
services within their scope of practice
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Behavioral health services, such as mental health, substance abuse treatment, and chemical
dependency services rendered by any of the following providers within the MCE’s network:
– Outpatient mental health clinics
– Community mental health centers (CMHCs)
– Psychologists
– Certified psychologists
– Health service providers in psychology (HSPPs)
– Certified social workers
– Certified clinical social workers
– Psychiatric nurses
– Independent practice school psychologists
– Advanced practice registered nurses, under IC 25-23-1-1(b), credentialed in psychiatric or
mental health nursing by the American Nurses Credentialing Center
– Persons holding a master’s degree in social work, marital and family therapy, or mental health
counseling (for outpatient mental health services as defined under Indiana Administrative Code
405 IAC 5-20-8)
Note: PMP referral is not the same as prior authorization. Contact the member’s MCE to
determine whether the service or procedure requires prior authorization. Self-referral
services may be subject to benefit limitations; providers should contact the MCE for
additional guidance.
Carved-Out Services
Claims for services provided under the managed care delivery system are submitted to the MCE in which
the HIP, Hoosier Care Connect, or Hoosier Healthwise member is enrolled (or to vendors contracted by
that entity). However, certain services are “carved out” of the managed care programs.
Carved-out services for managed care members are the financial responsibility of the State. These carved-
out services are billed as fee-for-service (FFS) claims and are submitted to and processed, directly or
indirectly, by DXC or, for pharmacy claims, OptumRx. Carved out services that require prior authorization
are submitted to the FFS PA contractor, Cooperative Managed Care Services (CMCS) or, for pharmacy
PA, to OptumRx.
Carved-out services include the following:
Services provided by a school corporation as part of a student’s Individualized Education Program
(IEP)
Medicaid Rehabilitation Option (MRO) services
(Note: MCEs must provide care coordination services and associated services related to MRO
services including, but not limited, to transportation.)
Crisis intervention services
First Steps services
The following pharmacy services:
– Hepatitis C drugs
– Cystic fibrosis drugs Kalydeco, Orkambi, and Symdeko
– Exondys 51
– Spinraza
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Designated physician-administered drugs, listed in Physician-Administered Drugs Carved Out of
Managed Care and Reimbursable Outside the Inpatient Diagnosis-Related Group, accessible from
the Code Sets page at in.gov/medicaid/providers
1915(i) State Plan Home and Community-Based Services (HCBS), provided through the Family and
Social Services Administration (FSSA) Division of Mental Health and Addiction (DMHA),
including:
– Adult Mental Health and Habilitation (AMHH) services
– Behavioral and Primary Healthcare Coordination (BPHC) services
– Child Mental Health Wraparound (CMHW) services
Excluded Services
In addition to certain services being carved out of the managed care program, some services are excluded
from managed care, and members must be disenrolled or suspended from managed care and moved to a
fee-for-service program when they qualify for such services. Examples include:
Psychiatric residential treatment facility (PRTF) services
Long-term care services in a nursing facility (NF) or an intermediate care facility for individuals
with intellectual disability (ICF/IID)
590 Program services
1915(c) HCBS waiver or Money Follows the Person (MFP) demonstration grant services, including:
– Aged and Disabled (A&D) Waiver services
– Traumatic Brain Injury (TBI) Waiver services
– Community Integration and Habilitation (CIH) Waiver services
– Family Supports Waiver (FSW) services
Healthy Indiana Plan
HIP is a program sponsored by the state of Indiana that provides an affordable healthcare choice to
thousands of individuals throughout Indiana. HIP provides health insurance for adults ages 19 through 64
whose income is at or under 138% of the federal poverty level (FPL), who are not on Medicare, and who
do not qualify for another Medicaid program. HIP is a managed care program with vision and dental
services, when applicable, carved into the managed care arrangement. Indiana offers HIP members a
comprehensive benefit package through a deductible health plan paired with a personal healthcare account
called a Personal Wellness and Responsibility (POWER) Account (sometimes referred to as a PAC). HIP
comprises the following distinct benefit plans:
HIP Plus: All HIP-eligible members are initially given the opportunity for coverage under the
HIP Plus enhanced benefit package. HIP Plus participation requires members to make monthly
POWER Account contributions, except for individuals exempt from cost-sharing. Member
eligibility in HIP Plus is not final until either the first POWER Account or Fast Track prepayment is
paid. To remain fully eligible for HIP Plus, members must continually make monthly POWER
Account contributions.
HIP Basic: HIP members with income at or below 100% FPL who do not make a Fast Track
prepayment or initial POWER Account payment, or who fail to make subsequent monthly POWER
Account payments, are not eligible for HIP Plus, and are transferred to the HIP Basic benefit plan.
HIP Basic requires the member to make copayments at the point of service for each service received
from a provider. Copayments for services received range from $4 to $8 for a doctor visit or
prescription filled, and may be as high as $75 for inpatient hospitalization. HIP Basic does not cover
vision, dental, or chiropractic services. Formulary for pharmacy is limited in the Basic plan.
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HIP State Plan Plus: The following HIP members qualify for HIP State Plan Plus:
– Section 1931-eligibile parents and caretaker relatives eligible under 24 CFR 435.110
– Low-income 19- and 20-year-old dependents eligible under 42 CFR 4.35.222
– Individuals determined to be eligible for transitional medical assistance by the State in
accordance with Section 1925 of the Social Security Act
– Individuals determined to be medically frail (see the Medically Frail Individuals section)
HIP members with this benefit plan have the same cost-sharing requirements as HIP Plus – they must
make monthly POWER Account contributions, and they only have copayments on nonemergency use
of the hospital emergency department. (Members who are American Indian/Alaska Natives are not
required to make copayments or financial contributions to a POWER Account).
HIP State Plan Plus Copay: This benefit plan is available to members with an income between
100% and 133% FPL, who were eligible under HIP State Plan Plus due to a determination of being
medically frail, and who fail to make ongoing financial contributions to a POWER Account. Under
this benefit plan, members receive full State Plan (Package A) benefits but are required to pay
copays. Additionally, unpaid POWER Account payments accrue as debt to the member for each
month they are enrolled in HIP State Plan Plus Copay.
HIP State Plan Basic: This benefit plan is available to members with income at or below 100%
FPL, who were eligible under HIP State Plan Plus, and who fail to make financial contributions to a
POWER Account. This plan offers access to all benefits available under the State Plan. Members
with this benefit package have the same cost-sharing requirements and copayments for all services
as HIP Basic members.
HIP Maternity: This benefit plan offers access to all benefits available under the State Plan, with no
cost-sharing, to pregnant women who are enrolled in or determined eligible for HIP. During the
member’s pregnancy and for a 60-day postpartum period, HIP Maternity offers enhanced benefits
including vision, dental, and chiropractic services; nonemergency transportation; and enhanced
smoking cessation services.
For more information about HIP and applying for benefits, see the HIP website at in.gov/fssa/hip or call
1-877-GET-HIP9. Applicants may select an MCE on the application or one will be auto-assigned, if not
already assigned for the current calendar year. HIP applicants must also be assigned to a primary medical
provider (PMP). The MCE will assist with the PMP assignment. Applicants who are not already assigned a
current calendar-year MCE are able to change MCEs before their Fast Track payment or before their first
POWER Account contribution is made. After payment, HIP members are not be able to make MCE
changes until the annual MCE selection period (November 1 through December 15), unless they have an
unresolved just-cause issue. Members will start with their newly selected MCE the first day (January 1) of
the following year.
If a $10 Fast Track prepayment was not made at the time of application, the selected MCE sends the
applicant an invoice for the payment. HIP applicants have 60 days from the date on the invoice to make
either a Fast Track payment or their first POWER Account contribution to be enrolled in HIP Plus.
Individuals approved for HIP who are still in the initial 60-day payment period and who have not yet paid
their Fast Track payment or first POWER Account contribution are referred to as conditionally eligible.
These individuals do not become fully eligible, nor enrolled as a member, until one of the following occurs:
Fast Track payment (if Fast Track eligible)
Payment of their first POWER Account contribution
The expiration of the 60-day payment period (for individuals at or below 100% FPL)
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Coverage for HIP Plus begins on the first day of the month in which the Fast Track payment or initial
monthly POWER Account contribution was paid. Coverage may occur in a different month from that in
which payment was made in the following situations:
If the member was previously covered under a different Medicaid category (for example, Family
Planning or Presumptive Eligibility) and is transitioning to HIP
If the member was not Fast Track eligible (did not complete redetermination)
If the member paid an MCE that he or she was not assigned to
Individuals who choose not to make their initial contribution will remain conditionally eligible and will be
unable to receive coverage for services while they are conditionally eligible. If no payment has been made
when the 60-day payment period expires, one of the following occurs:
Individuals with income at or below 100% of the FPL will be enrolled in HIP Basic, with coverage
effective the first day of the month in which the 60th day occurs.
Individuals with income over 100% of the FPL will not be enrolled. They will need to reapply to
receive HIP coverage.
Member Eligibility for HIP
Eligibility for HIP is limited to Indiana residents ages 19 through 64 whose family income is up to 133% of
the FPL. A 5% income disregard is applied to determine eligibility if an individual is found ineligible at
133% FPL but would be income-eligible with the disregard. Individuals with Medicare do not qualify.
The following categories of individuals are eligible to receive HIP State Plan benefits:
Section 1931 eligible parents and caretaker relatives eligible under Code of Federal Regulations 42
CFR 435.100
Low-income 19- and 20-year-old dependents
Members determined eligible for transitional medical assistance by the State in accordance with
Section 1925 of the Social Security Act
Individuals deemed to be medically frail, as defined by 42 CFR 440.315(f)
HIP-eligible pregnant women receive full State Plan benefits under HIP Maternity without cost-sharing
obligations. All other HIP members eligible for State Plan benefits are enrolled in HIP State Plan Plus or
HIP State Plan Basic, and are subject to the same cost-sharing components as HIP Plus or HIP Basic
members, through either a POWER Account contribution or copayments.
Pregnant Women
Pregnant applicants with income at or below 138% of the FPL and who meet all other HIP eligibility
criteria will be enrolled in the HIP Maternity benefit plan, which provides full State Plan benefits, free of
cost-sharing obligations.
Note: Pregnant applicants with income above 138% of the FPL and eligible for IHCP
services will be enrolled in Hoosier Healthwise, with Package A – Standard Plan
coverage, which provides the same benefits as HIP Maternity.
If a woman is already enrolled in HIP when she becomes pregnant, her coverage will be converted to the
HIP Maternity benefit plan beginning the first of the month following notification of pregnancy, and will
continue under that benefit plan until her postpartum coverage period is over. The postpartum coverage
period lasts at least 60 days from pregnancy termination date. HIP members retain coverage through the
HIP program, under their existing MCE, during pregnancy and at redetermination as long as they continue
to meet eligibility requirements.
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Pregnant applicants enrolling in HIP may also be determined eligible for retroactive coverage for up to
3 months prior to their application date. If the applicant is eligible for retroactive coverage, the IHCP EVS
will indicate Package A – Standard Plan as the member’s coverage during the retroactive time period, with
no enrolling MCE indicated. Retroactive coverage is paid through the FFS delivery system. See the
Retroactive Member Eligibility section for more information.
Medically Frail Individuals
Within the HIP-eligible population, the IHCP identifies those members who may be medically frail and
provides enhanced coverage for those individuals who meet the medically frail criteria. HIP-eligible
medically frail individuals are enrolled in one of the HIP State Plan options and receive comprehensive
State Plan benefits equivalent to Package A benefits, including nonemergency transportation to medical
appointments.
Federal regulation 42 CFR 440.315(f) defines the medically frail as individuals with one or more of the
following:
Disabling mental disorder
Chronic substance abuse disorder
Serious and complex medical condition
Physical, intellectual, or developmental disability that significantly impair the individual’s ability to
perform one or more activities of daily living
Disability determination based on Social Security Administration (SSA) criteria
Each MCE is responsible for identifying and verifying all its members who are medically frail. However,
members with a disability determination based on SSA criteria or members who are confirmed by the
Indiana State Department of Health to have human immunodeficiency virus (HIV) or acquired immune
deficiency syndrome (AIDS) are automatically confirmed medically frail by the State. The MCE is not
responsible for verifying the medically frail designation of the members identified as such by the State, and
these HIP members automatically qualify for enrollment into HIP State Plan benefits.
MCEs verify through claims or supplemental information utilizing the Milliman Medical Underwriting
Guidelines to determine whether members qualify as medically frail. Members with a qualifying condition
will be assessed by their MCE to verify that the condition is active and to determine how well the condition
is controlled, as well as to identify any complicating comorbidities. Those members designated medically
frail as a result of the MCE’s assessment will be enrolled in the HIP State Plan option the first day of the
following month after the assessment is sent to the State.
Like all HIP-eligible individuals, medically frail HIP members will be enrolled with one of the HIP MCEs
and required to contribute to a POWER Account or make copayments. Medically frail members will be
enrolled in HIP State Plan Plus if they make their Fast Track payment or monthly POWER Account
contribution. Members at or below 100% FPL who do not make their monthly contributions will be
enrolled in HIP State Plan Basic. Although medically frail individuals are exempt from being locked out
of the program for nonpayment of POWER Account contributions, those with incomes higher than 100%
of the FPL who do not make their required contributions will continue to owe their required POWER
Account contribution amounts and will also incur additional costs in the form of copayments until their
owed contribution amount has been paid. The EVS identifies coverage during this time as HIP State Plan
Plus Copay.
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Personal Wellness and Responsibility Account and Copayments
All HIP members, except HIP Maternity members and American Indian or Alaska Native members, have a
POWER Account. The POWER Account is modeled in the spirit of a traditional Health Savings Account
(HSA) and is funded with State and member contributions. Employers and other third parties (such as
nonprofit organizations and family members) may also contribute some or all of the member’s POWER
Account contribution. Members use POWER Account funds to meet the $2,500 deductible. POWER
Accounts are funded with post-tax dollars and are not considered HSAs or other health spending accounts
(for example, Flexible Spending Accounts or Health Reimbursement Accounts) under federal law. POWER
Accounts are not subject to regulation under the U.S. Tax Code, as such.
The POWER Account comprises a monthly member contribution plus a State contribution. Members pay a
monthly contribution for HIP Plus coverage. HIP POWER Account contribution amounts are tiered and
based on FPL percentage ranges and will not exceed 5% of the member’s annual household income. In the
case where two members are married, the combined total of both spouses’ required POWER Account
contributions cannot exceed 2% of the monthly household income. The maximum combined total annual
amount of the POWER Account is $2,500 and is used to pay the initial eligible expenses or the deductible
to participating providers. If a POWER Account is not fully funded, the MCE is still required to pay all
claims. A member’s monthly POWER Account contribution is determined using the criteria shown in
Table 3:
Table 3 –Member’s Monthly POWER Account Contribution Requirements Based on Income
Yearly Income Monthly POWER Account Contribution
Single Individual Spouses (Each)
Up to and including 22% of the FPL $1.00 $1.00
Above 22% of the FPL and up to and including
50% of the FPL
$5.00 $2.50
Above 50% of the FPL and up to and including
75% of the FPL
$10.00 $5.00
Above 75% of the FPL and up to and including
100% of the FPL
$15.00 $7.50
Above 100% of the FPL and up to and including
133% of the FPL
$20.00 $10.00
Note: Beginning in January 2019, members may be assessed a 50% tobacco use surcharge in
addition to the POWER Account tier amounts listed in this table.
Members enrolled in HIP Basic or HIP State Plan Basic are not required to make monthly contributions to
their POWER Account, but are required to make copayments, which are assessed as one payment per type
of service, per provider, per day (or one payment per inpatient stay). See Table 4 for applicable copayment
amounts. Designated preventive care services (see IHCP Bulletin BT201969), are excluded from the
copayment requirement.
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Table 4 – Copayment Requirements for HIP Basic, HIP State Plan Basic, and HIP State Plan Plus Copay
Service Copayment
Preventive care (including Early Periodic Screening,
Diagnostic, and Testing [EPSDT] services for 19- and
20-year-old members)
No copayment
Medical services $4
Outpatient services $4
Inpatient services $75
Preferred drugs $4
Nonpreferred drugs $8
Nonemergency use of the emergency room $8 (except for individuals who call the MCE
24-hour nurse hotline before using the ER,
for whom the copayment is then waived)
Covered Services
HIP coverage is focused on preventive services and covers essential medical services, similar to
commercial plans. All preventive services set forth in federal regulations will be administered free of cost
sharing and will not be debited from the POWER Account. If additional preventive services are offered, the
first $500 of these services do not require member contributions from the POWER Account.
Table 5 lists categories of services and indicates whether HIP Basic, HIP Plus, HIP State Plan, and HIP
Maternity include benefits within each category.
For information about provider billing and reimbursement for services delivered to HIP members, contact
the member’s MCE. MCE contact information is included in the IHCP Quick Reference Guide available
at in.gov/medicaid/providers.
Table 5 – HIP Benefit Comparison by Plan
Services HIP Basic HIP Plus HIP State Plan
or HIP Maternity
Ambulatory patient services Yes Yes Yes
Bariatric surgery No Yes Yes
Behavioral health services Yes Yes Yes
Chiropractic services No Yes
(6 spinal
manipulations per
calendar year)
Yes
(50 units per
calendar year)
Chronic disease management Yes Yes Yes
Dental services No Yes Yes
Early and Periodic Screening, Diagnostic,
and Treatment (EPSDT) services, as
defined at 42 USC 1396d(r), for 19- and
20-year-old members
Yes Yes Yes
Emergency services Yes Yes Yes
Hospitalization Yes Yes Yes
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Services HIP Basic HIP Plus HIP State Plan
or HIP Maternity
Laboratory services Yes Yes Yes
Maternity services Yes Yes Yes
Medicaid Rehabilitation Option (MRO)
services
No No Yes
Mental health services Yes Yes Yes
Nonemergency transportation services No No Yes
Prescription drugs Yes Yes Yes
Preventive and wellness services Yes Yes Yes
Rehabilitative and habilitative services and
devices
Yes
(60 combined
outpatient
therapy visits *)
Yes
(75 combined
outpatient therapy
visits*)
Yes
Services that are not medically necessary No No No
Substance use disorder services Yes Yes Yes
Temporomandibular joint (TMJ) treatment
(surgical and nonsurgical)
No Yes Yes
Urgent care Yes Yes Yes
Vision services No Yes Yes
Any other services not approved by the
Centers for Medicare & Medicaid Services
(CMS) in the specified benefit plan
No No No
* Outpatient therapy limits are for the combined total of physical therapy, occupational therapy,
speech therapy, cardiac rehabilitation, and pulmonary rehabilitation visits annually.
Hoosier Care Connect
Hoosier Care Connect is a risk-based managed care program designed to improve the quality of care and
clinical outcomes for members eligible for the IHCP on the basis of age, blindness, or disability. Hoosier
Care Connect members pick and MCE and a primary doctor. The MCE assists members in coordinating
their healthcare benefits and tailoring the benefits to individual needs, circumstances, and preferences.
Hoosier Care Connect members receive full Medicaid State Plan benefits, in addition to care coordination
services and other FSSA-approved enhanced benefits developed by the MCEs.
Individuals in the following groups who meet eligibility criteria (including income guidelines, when
applicable) and who do not reside in an institution, are not receiving services through a home and
community-based services (HCBS) waiver, and are not enrolled in Medicare will be enrolled in Hoosier
Care Connect:
Aged individuals (age 65 and over)
Blind individuals
Disabled individuals
Individuals receiving Supplemental Security Income (SSI)
Individuals enrolled in Medicaid for Employees with Disabilities (M.E.D. Works)
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Children who fit the following descriptions may opt out of Traditional Medicaid (FFS) and voluntarily
enroll in Hoosier Care Connect:
Wards of the State
Foster children
Former foster children who turned 18 years of age while in foster care, are under age 26 (or under
age 21, if the foster care was outside of Indiana), and opt out of Hoosier Care Connect
Children receiving adoption assistance
Individuals will be removed from the Hoosier Care Connect program and transitioned to another IHCP
program if they:
Become eligible for Medicare
Enter a nursing home for a length of stay greater than 30 days
Enter a state psychiatric facility, a psychiatric residential treatment facility (PRTF), or an
intermediate care facility for individuals with intellectual disabilities (ICF/IID)
Become eligible for and choose to enter an HCBS waiver program
Hoosier Healthwise
The Hoosier Healthwise program provides coverage for children and for pregnant women who earn too
much to qualify for HIP (138% FPL) but remain Medicaid eligible by having family income under 208%
FPL.
Hoosier Healthwise assignment is mandatory for aid categories that include children and children who are
eligible for the Children’s Health Insurance Program (CHIP), unless they are a member of an exempted
group. The specific eligibility aid category (based on household income/size) determines the benefit
package.
The following IHCP members are excluded from mandatory assignment to Hoosier Healthwise managed
care:
Individuals in nursing homes and other institutions, such as PRTFs and ICFs/IID
Individuals receiving psychiatric treatment in a state hospital
Immigrants who qualify for Emergency Services Only (Package E) coverage
Individuals receiving HCBS waiver services
Individuals who are eligible for and opt to receive IHCP hospice services
Members with HCBS waiver liability or end-stage renal disease (ESRD) waiver liability
Members eligible for the Family Planning Eligibility Program
Table 6 explains the Hoosier Healthwise benefit packages.
Table 6 – Hoosier Healthwise Benefit Package Explanation
Benefit Package Coverage
Package A Full coverage for eligible children and pregnant women
Package C Preventive, primary, and acute care services for eligible children
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The Division of Family Resources (DFR) determines whether an applicant is approved for eligibility in
Hoosier Healthwise. The member may choose an MCE on the application. After the DFR approves an
applicant’s eligibility, the member will immediately be assigned to the MCE that was chosen on the
application or, if no MCE was chosen, to an MCE that is automatically selected for that member.
Note: Enrollment for newborns whose mothers are enrolled in Package A with an MCE on
the date of delivery is retroactive, with the mother’s MCE, to the newborn’s date of
birth.
Upon enrollment with an MCE, the member begins a 90-day “free change” period. During the free change
period, the member may change from one MCE to another for any reason. When the free change period
ends, the member remains with his or her chosen MCE for 9 months and may not move to another MCE
except for reasons that meet the standard of just cause. Just cause reasons include:
Lack of access to medically necessary services covered under the MCE’s contract with the State
Service not covered by the MCE for moral or religious objections
Related services required to be performed at the same time
– Not all related services are available within the MCE’s network, and the member’s PMP or
another provider determines
– that receiving the services separately would subject the member to unnecessary risk
Lack of access to providers experienced in dealing with the member’s healthcare needs
Concerns over quality of care
– Poor quality of care includes failure to comply with established standards of medical care
administration and significant language or cultural barriers.
Member’s PMP disenrollment from member’s current MCE
– If a member’s PMP disenrolls from the member’s current MCE and reenrolls into a new MCE,
the member can change plans to follow his or her PMP to the new MCE.
During the annual redetermination period, members may choose a different PMP within their selected MCE.
Package A
Hoosier Healthwise Package A – Standard Plan coverage encompasses the full array of Medicaid State
Plan benefits for children and pregnant women who meet the following guidelines:
Pregnant women: 139% – 208% FPL
Children (under age 19): Under 158% FPL
Package A members do not have copayment or other cost-sharing requirements to receive covered
healthcare services.
IHCP applicants determined eligible for Hoosier Healthwise Package A may also be determined eligible for
retroactive coverage for up to 3 months prior to their application date. With the exception of newborns
whose mothers were enrolled with a managed care assignment on the date of the child’s birth, members
determined retroactively eligible under a Hoosier Healthwise aid category are covered through the FFS
delivery system during the retroactive period. See the Retroactive Member Eligibility section for more
information.
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Package C
Hoosier Healthwise Package C – Children’s Health Plan (SCHIP) provides preventive, primary, and acute
healthcare coverage to children who meet the following eligibility criteria:
The child must be younger than 19 years old.
The child’s family income must be between 158% and 250% of the federal poverty level.
The child must not have creditable health coverage or have had creditable health coverage at any
time during a waiting period lasting no longer than 90 days.
The child’s family must financially satisfy payment of monthly premiums.
Package C members fall under the State Children’s Health Insurance Program (SCHIP).
Enrollment Process and Cost-Sharing Requirements
A child determined eligible for Package C is made conditionally eligible pending a premium payment. The
child’s family must pay a monthly premium, as shown in Table 7. After the first premium is paid, eligibility
information is transferred to CoreMMIS.
Table 7 – Hoosier Healthwise Package C Premium Comparison
Income (As a Percentage of the
Federal Poverty Level)
Monthly Premiums
One Child Two or More
151% through 175% $22 $33
176% through 200% $33 $50
201% through 225% $42 $53
226% through 250% $53 $70
Enrollment continues as long as premium payments are received and the child continues to meet all
eligibility requirements. Enrollment is terminated for nonpayment of premiums after a 60-day grace period.
Package C members may be eligible for coverage no earlier than the first day of the month that the Indiana
Application for Health Coverage was received. Package C members do not have retroactive eligibility,
unless they are determined retroactively eligible for coverage under a different eligibility category or
package, as described in the Limited Retroactive Eligibility for Hoosier Healthwise Package C Members
section.
The child’s family may also be required to make copayments for ambulance transportation and pharmacy
services. Providers are responsible for collecting copayments, and the copayment amount is deducted
from the claim. Specific information about Package C member copayments is included in the Service-Specific
Copayment Policies section of this module.
Coverage and Limitations
Children enrolled in Package C are eligible for the following benefits:
Ambulance transportation
Anesthesia
Certified nurse-midwife services
Chiropractic services
Clinic services
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Diabetes self-management training
Dental services
Early intervention services
Food supplements, nutritional supplements, and infant formulas
Home health services
Hospice (under fee-for-service only)*
Hospital services
Inpatient rehabilitative services
Laboratory services
Radiology services
Medical supplies and equipment
Mental health and substance abuse services
Physicians’ surgical and medical services
Podiatry services
Prescription drugs
Therapies
Vision services
*Note: Hospice is a covered benefit for Package C members, but the member must be
disenrolled from managed care and enrolled in Traditional Medicaid to receive IHCP
hospice services. See the Hospice Services module for more information.
The following services have coverage limitations and policies under Hoosier Healthwise Package C that
differ from those limitations required by Hoosier Healthwise Package A:
Emergency ambulance transportation – Package C is covered for emergency ambulance
transportation, subject to the prudent layperson standard as defined in 405 IAC 13-8-1. This service
is subject to a $10 copayment.
Nonemergency ambulance transportation – Ambulance service for nonemergencies between
medical facilities is covered when requested by a participating physician. A $10 copayment applies.
All other nonemergency transportation is not covered for Package C.
Chiropractic services – Coverage is limited to five visits and 14 therapeutic physical medicine
treatments per member per year. An additional 36 treatments may be covered if prior authorization
(PA) is obtained based on medical necessity.
Early intervention services – Package C covers immunizations and initial and periodic screenings
according to the EPSDT/HealthWatch periodicity and screening schedule (see the Early and
Periodic Screening, Diagnostic, and Treatment (EPSDT)/HealthWatch Services module). Coverage
of referral and treatment services is subject to the Package C benefit limitations.
Inpatient rehabilitative services – Coverage is available for a maximum of 50 days per calendar
year.
Medical supplies and equipment – Coverage is available for a maximum benefit of $2,000 per year
and $5,000 per lifetime per member.
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Podiatry services – Surgical procedures involving the foot (which may include laboratory or x-ray
services and hospital stays) are covered when medically necessary.
Prescription drugs – The pharmacists provide a brand-name drug only when the prescribing
physician writes Brand Medically Necessary on the prescription. The generic equivalent of a brand
name drug will be substituted if one is available and the substitution results in a lower price. The
medication should be dispensed as written; the pharmacist must dispense the drug prescribed.
Pharmacy copayments for members enrolled in Hoosier Healthwise Package C continue to be $3 for
generic drugs and $10 for brand name drugs.
Therapies – Physical, speech, occupational, and respiratory therapy are covered for a maximum of
50 visits per year per type of therapy.
Note: The MCEs may have different PA requirements and should be contacted for specific
information.
Wraparound Services
Children enrolled in Hoosier Healthwise, including children enrolled in Package C, may be eligible for
additional health coverage from the following programs:
Indiana First Steps – This program provides early intervention services including:
– Screenings and assessments
– Planning and service coordination
– Therapeutic services
– Support services
– Information and communication to infants and toddlers who have disabilities or who are
developmentally vulnerable
Children’s Special Health Care Services (CSHCS) at ISDH – The CSHCS program provides
healthcare services for children through age 21 who have a severe chronic medical condition that:
– Has lasted or is expected to last at least 2 years
– Will produce disability, disfigurement, or limits on function
– Requires a special diet or devices
– Would produce a chronic disabling condition without treatment
Both programs require the assistance of healthcare professionals to identify children for assessment
and diagnostic evaluations, and to provide diagnoses and referrals. Additional information about the
programs may be obtained by calling First Steps at 1-800-545-7763 or accessing the First Steps web page
at in.gov/fssa and by calling CSHCS at 1-800-475-1355 or accessing the CSHCS website at in.gov/isdh.
Billing Procedures
The billing procedures for Package C are the same as those for the other Hoosier Healthwise benefit plans.
Even though children enrolled in Hoosier Healthwise Package C should not have other minimal essential
coverage, providers are required to bill all other insurance carriers prior to billing the IHCP if additional
insurance coverage is discovered.
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Hoosier Healthwise Package Comparison
Table 8 compares benefit packages of the Hoosier Healthwise program. The following items apply
throughout the table:
Package A covered services and limitations are cited in 405 IAC 5; Package C covered services and
limitations are cited in 405 IAC 13. See the Indiana Administrative Code (IAC) page at in.gov.
Covered services not reimbursed by MCEs are covered and reimbursed for Hoosier Healthwise
members under fee-for-service (FFS) reimbursement, unless otherwise indicated in Package A and C.
Table 8 – Comparing Hoosier Healthwise Benefit Packages A and C
Benefit Reimbursed
by MCE Package A Package C
Applied Behavior
Analysis (ABA)
Therapy
(405 IAC 5-22)
Yes Coverage is available for members
under the age of 21 diagnosed with
an autism spectrum disorder.
Services must be provided in
accordance with the State Plan and
the IAC.
Coverage is available for members
diagnosed with an autism spectrum
disorder. Services must be provided
in accordance with the IAC.
Behavioral Health
(Mental Health and
Substance Use
Disorder
Treatment)
Services –
Outpatient*
(405 IAC 5-20-8)
Yes
(Except MRO
services, which
are reimbursed
FFS; self-
referral)
Coverage includes outpatient
mental health and substance use
disorder services (including partial
hospitalization services), as
defined in 405 IAC 5-20-8,
provided by physicians,
psychiatric wings of acute care
hospitals, outpatient mental health
facilities, and psychologists
endorsed as health services
providers in psychology (HSPPs).
Limited to one evaluation and five
psychotherapy visits per year
without prior authorization.
MCEs are responsible for
methadone treatment provided in a
clinic setting.
Unless otherwise provided by
IC 12-17.6-4-2, outpatient mental
health and substance use disorder
services are covered subject to the
same coverage policies and benefit
limitations as apply to Package A.
MCEs are responsible for
methadone treatment provided in a
clinic setting.
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Benefit Reimbursed
by MCE Package A Package C
Behavioral Health
(Mental Health and
Substance Use
Disorder
Treatment)
Services –
Inpatient**
(Freestanding
Psychiatric Facility
or Psychiatric Unit
of an Acute Care
Hospital)
(405 IAC 5-20)
Yes Coverage includes inpatient mental
health and substance use disorder
services in a psychiatric unit of an
acute care hospital or in a certified
psychiatric hospital with 16 beds
or fewer.
For members under 21 years of age
(or under 22 and began inpatient
psychiatric services immediately
before their 21st birthday),
coverage includes inpatient mental
and behavioral health services in
an institution of mental disease
(IMD) with more than 16 beds.
MCEs may authorize coverage
for short-term stays for members
21–64 years of age an IMD in lieu
of services or settings covered
under Indiana’s Medicaid State
Plan.
Unless otherwise provided by
IC 12-17.6-4-2, inpatient mental
health and substance use disorder
services are covered subject to the
same coverage policies and benefit
limitations as applied under
Package A.
Behavioral Health
(Mental Health and
Substance Use
Disorder
Treatment)
Services –
Inpatient**
(State Psychiatric
Hospital)
(405 IAC 5-20-1)
No Covered for individuals under age
21 if in a certified wing.
Member must be disenrolled
from Hoosier Healthwise and
enrolled in Traditional Medicaid
for the benefit to begin.
Unless otherwise provided by
IC 12-17.6-4-2, inpatient mental
health and substance use disorder
services are covered subject to the
same coverage policies and benefit
limitations as apply to Package A.
Member must be disenrolled
from Hoosier Healthwise and
enrolled in Traditional Medicaid
for the benefit to begin.
Chiropractic
Services*
(405 IAC 5-12)
Yes
(Self-referral)
Coverage is available for covered
services provided by a licensed
chiropractor. Reimbursement is
limited to a total of 50 office visits
or treatments per member per year,
which includes a maximum
reimbursement of no more than
five office visits per member, per
year. For example, a chiropractor
may bill for a maximum of five
visits and 45 treatments (5 + 45 =
50), but may not bill for 50
treatments and five visits (50 + 5 =
55).
Coverage is available for covered
services provided by a licensed
chiropractor. Reimbursement is
limited to five visits and 14
therapeutic physical medicine
treatments per member per year.
An additional 36 treatments may be
covered if prior authorization is
obtained based on medical
necessity. There is a 50-treatment
limit per year.
Chronic Disease
Management
Yes Coverage is available to qualified
members with chronic diseases
such as congestive heart failure,
diabetes, and asthma, to enhance,
support, or train on self-
management skills.
Coverage is available to qualified
members with chronic diseases
such as congestive heart failure,
diabetes, and asthma to enhance,
support, or train on self-
management skills.
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Benefit Reimbursed
by MCE Package A Package C
Dental Services
(405 IAC 5-14)
Yes
(Routine dental
services are
self-referral
within the
member’s MCE
network)
Coverage for members age 21 and
older includes dental services as
described in 405 IAC 5-14. For
children under age 21, all
medically necessary dental
services are covered, even if the
service is not otherwise covered
under Package A.
No orthodontic procedures are
approved except in cases of
craniofacial deformity or cleft
palate.
All medically necessary dental
services are provided for children
enrolled in Package C, even if the
service is not otherwise covered
under CHIP.
No orthodontic procedures are
approved except in cases of
craniofacial deformity or cleft
palate.
Diabetes Self-
Management
Training Services*
(405-IAC 5-36)
Yes
(Self-referral)
Coverage is limited to 16 units per
member, per year. Additional units
may be prior authorized.
Coverage is limited to 16 units per
member, per year. Additional units
may be prior authorized.
Drugs – Prescribed
(Legend)
(405 IAC 5-24)
Yes (except
drugs indicated
in the Carved-
Out Services
section, which
are reimbursed
as FFS)
Covers legend drugs if the drug is:
Approved by the U.S. Food
and Drug Administration
(FDA)
Not designated by the Centers
for Medicare & Medicaid
Services (CMS) as less than
effective or identical, related,
or similar to a less than
effective drug or terminated
Not specifically excluded
from coverage by the IHCP
Covers legend drugs if the drug is:
Approved by the U.S. FDA
Not designated by the CMS as
less than effective or identical,
related, or similar to a less
than effective drug or
terminated
Not specifically excluded
from coverage by the IHCP
Drugs –
Over-the-Counter
(Nonlegend)
Yes Covers nonlegend (over-the-
counter) drugs on the MCE
formularies. Formularies are
available from the MCE websites
listed on the Pharmacy Services
page at in.gov/medicaid/providers.
Covers nonlegend (over-the-
counter) drugs on the MCE
formularies. Formularies are
available from the MCE websites
listed on the Pharmacy Services
page at in.gov/medicaid/providers.
Early Intervention
Services (EPSDT)
(405 IAC 5-15)
Yes
(Immunizations
are self-
referral)
Covers comprehensive health and
development history,
comprehensive physical exam,
appropriate immunizations,
laboratory tests, health education,
vision services, dental services,
hearing services, and other
necessary healthcare services
from birth through the month
of the member’s 21st birthday,
as described in the
EPSTD/HealthWatch Services
module).
Covers immunizations and
initial and periodic screenings
as described in the
EPSTD/HealthWatch Services
module. Coverage of treatment
services is subject to the Package C
benefit plan coverage limitations.
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Benefit Reimbursed
by MCE Package A Package C
Emergency
Services
(IC 12-15-12-15
and
IC 12-15-12-17)
Yes
(Self-referral)
Emergency services are covered
subject to the prudent layperson
standard of an emergency medical
condition. All medically necessary
screening services provided to an
individual who presents to an
emergency department with an
emergency medical condition are
covered.
Emergency services are covered
subject to the prudent layperson
standard of an emergency medical
condition. All medically necessary
screening services provided to an
individual who presents to an
emergency department with an
emergency medical condition are
covered.
Eye Care,
Eyeglasses, and
Vision Services
(405 IAC 5-23)
Yes
(Self-referral,
except for
surgical
services)
Coverage for the initial vision care
examination is limited to one
examination per year for a member
under 21 years of age, and one
examination every 2 years for a
member 21 years of age or older,
unless more frequent care is
medically necessary.
Coverage for eyeglasses, including
frames and lenses, is limited to a
maximum of one pair per year for
members under 21 years of age and
one pair every 5 years for members
21 years of age and older.
Exceptions are when a specified
minimum prescription change
makes additional coverage
medically necessary or the
member’s lenses and/or frames are
lost, stolen, or broken beyond
repair.
Vision care examination is limited
to one examination per year, unless
more frequent care is medically
necessary.
Coverage for eyeglasses, including
frames and lenses, is limited to a
maximum of one pair per year,
except when a specified minimum
prescription change makes
additional coverage medically
necessary or the member’s lenses
and/or frames are lost, stolen, or
broken beyond repair.
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Benefit Reimbursed
by MCE Package A Package C
Family Planning
Services and
Supplies
Yes
(Self-referral)
Family planning services include:
Limited history and physical
examination
Pregnancy testing and
counseling
Provision of contraceptive
pills, devices, and supplies
Education and counseling on
contraceptive methods
Laboratory tests, if medically
indicated as part of the
decision-making process for
choice of contraception
Diagnosis and treatment of
sexually transmitted diseases
(STDs) and sexually
transmitted infections (STIs)
Screening and counseling of
members at risk for human
immunodeficiency virus
(HIV), and referral and
treatment
Tubal ligation
Vasectomies
Hysteroscopic sterilization
with an implant device
(Essure)
Cytology (Pap tests) and
cervical cancer screening,
including high-risk human
papillomavirus (HPV) DNA
testing, if performed
according to the United States
Preventative Services Task
Force guidelines
Family planning services include:
Limited history and physical
examination
Pregnancy testing and
counseling
Provision of contraceptive
pills, devices, and supplies
Education and counseling on
contraceptive methods
Laboratory tests, if medically
indicated as part of the
decision-making process for
choice of contraception
Diagnosis and treatment of
STDs and STIs
Screening and counseling of
members at risk for HIV and
referral and treatment
Tubal ligation
Vasectomies
Hysteroscopic sterilization
with an implant device
(Essure)
Cytology (Pap tests) and
cervical cancer screening,
including high-risk HPV
DNA testing, if performed
according to the United States
Preventative Services Task
Force guidelines
Federally Qualified
Health Centers
(FQHCs)
(405 IAC 5-16-5)
Yes Coverage is available for medically
necessary services provided by
licensed healthcare practitioners.
Coverage is available for medically
necessary services provided by
licensed healthcare practitioners.
Food Supplements,
Nutritional
Supplements, and
Infant Formulas**
(405 IAC 5-24-9)
Yes Coverage is available only when
no other means of nutrition is
feasible or reasonable. Not
available in cases of routine or
ordinary nutritional needs.
Coverage is available only when no
other means of nutrition is feasible
or reasonable. Not available in
cases of routine or ordinary
nutritional needs.
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Benefit Reimbursed
by MCE Package A Package C
Hospital Services –
Inpatient*
(405-IAC 5-17)
Yes Inpatient services are covered
when such services are provided or
prescribed by a physician and
when the services are medically
necessary for the diagnosis or
treatment of the member’s
condition.
Inpatient services are covered when
such services are provided or
prescribed by a physician and when
the services are medically
necessary for the diagnosis or
treatment of the member’s
condition.
Hospital Services –
Outpatient*
(405 IAC 5-17)
Yes Outpatient hospital services are
covered when such services are
provided or prescribed by a
physician and when the services
are medically necessary for the
diagnosis or treatment of the
member’s condition.
Outpatient hospital services are
covered when such services are
provided or prescribed by
a physician and when the services
are medically necessary for the
diagnosis or treatment of the
member’s condition.
Home Health
Services**
(405 IAC 5-16)
Yes Home health coverage is available
for medically necessary skilled
nursing services provided by a
registered nurse or licensed
practical nurse; home health aide
services; physical, occupational,
and respiratory therapy services;
speech pathology services; and
renal dialysis for home-bound
individuals.
Home health coverage is available
for medically necessary skilled
nursing services provided by a
registered nurse or licensed
practical nurse; home health aide
services; physical, occupational,
and respiratory therapy services;
speech pathology services; and
renal dialysis for home-bound
individuals.
Hospice Services**
(405 IAC 5-34)
No Hospice is available under
Traditional Medicaid if the
recipient is expected to die from
illness within 6 months. Coverage
is available for two consecutive
periods of 90 calendar days
followed by an unlimited number
of periods of 60 calendar days.
Member must be disenrolled
from Hoosier Healthwise
managed care and enrolled in
Traditional Medicaid (FFS)
before hospice benefits can
begin.
Hospice is available under
Traditional Medicaid if the
recipient is expected to die from
illness within 6 months. Coverage
is available for two consecutive
periods of 90 calendar days
followed by an unlimited number
of periods of 60 calendar days.
Member must be disenrolled
from Hoosier Healthwise
managed care and enrolled in
Traditional Medicaid (FFS)
before hospice benefits can begin.
Laboratory and
Radiology Services
(405 IAC 5-18 and
405 IAC 5-27)
Yes Coverage is available for medically
necessary laboratory and radiology
services, when ordered by a
physician.
Coverage is available for medically
necessary laboratory and radiology
services, when ordered by a
physician.
Long-Term
Acute Care
Hospitalization **
(See the Inpatient
Hospital Services
module)
Yes Long-term acute care services are
covered. An all-inclusive per diem
rate is paid based on level of care.
Long-term acute care services are
covered up to 50 days per calendar
year. An all-inclusive per diem rate
is based on level of care.
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Benefit Reimbursed
by MCE Package A Package C
Medical Supplies
and Equipment
(includes prosthetic
devices, implants,
hearing aids,
dentures, and so
forth)**
(405 IAC 5-19)
Yes Coverage is available for medical
supplies, equipment, and
appliances suitable for use in the
home when medically necessary.
Covered when medically necessary.
Maximum benefit of $2,000 per
year or $5,000 per lifetime for
durable medical equipment.
Equipment may be purchased or
leased, depending on which is more
cost efficient.
Medicaid
Rehabilitation
Option (MRO) –
Community Mental
Health Centers *
(405 IAC 5-22-1)
No; reimbursed
FFS
Coverage includes community-
based mental healthcare services
(such addiction counseling,
behavioral health counseling and
therapy, and case management),
for members with serious mental
illness, youth with serious
emotional disturbance, and
individuals with substance use
disorders. See the Medicaid
Rehabilitation Option Services
module for details.
Coverage includes community-
based mental healthcare services
(such addiction counseling,
behavioral health counseling and
therapy, and case management), for
members with serious mental
illness, youth with serious
emotional disturbance, and
individuals with substance use
disorders. See the Medicaid
Rehabilitation Option Services
module for details.
Nurse Midwife
Services
(405 IAC 5-22-3)
Yes Coverage of certified nurse-
midwife services is restricted to
services that the nurse-midwife is
legally authorized to perform.
Coverage of certified nurse-
midwife services is restricted to
services that the nurse-midwife is
legally authorized to perform.
Nurse Practitioner
Services
(405 IAC 5-22-4)
Yes Coverage is available for medically
necessary services or preventative
healthcare services provided by a
licensed, certified nurse
practitioner within the scope of the
applicable license and certification.
Coverage is available for medically
necessary services or preventative
healthcare services provided by a
licensed, certified nurse practitioner
within the scope of the applicable
license and certification.
Nursing Facility
Services –
Long-Term**
(405 IAC 5-31-1,
see the Long-Term
Care module)
No Long-term care nursing facility
services require preadmission
screening for LOC determination.
Member must be disenrolled
from Hoosier Healthwise and
enrolled in Traditional Medicaid
for the benefit to begin.
For a maximum of 60 days prior to
LOC determination, coverage is
available under managed care.
Coverage includes room and
board, nursing care, medical
supplies, durable medical
equipment, and transportation.
Noncovered
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Benefit Reimbursed
by MCE Package A Package C
Nursing Facility
Services –
Short-Term
(405 IAC 5-31-1)
Yes The MCE may obtain services for
its members in a nursing facility
setting on a short-term basis (fewer
than 30 consecutive calendar
days). This may occur if this
setting is more cost-effective than
other options and the member can
obtain the care and services needed
in the nursing facility. The MCE
can negotiate rates for reimbursing
the nursing facilities for these
short-term stays.
Coverage includes room and
board, nursing care, medical
supplies, durable medical
equipment, and transportation.
Note: MCEs may be responsible
for payment for up to 60 calendar
days for members placed in a long-
term care facility while the level of
care determination is pending,
allowing the member to be
transitioned to FFS coverage.
Noncovered
Nursing Facility
Services –
Intermediate Care
Facilities for
Individuals with
Intellectual
Disability
(ICFs/IID) –
Long-Term**
(405 IAC 5-13-2;
see the Long-Term
Care module)
No Long-term ICF/IID services
require preadmission screening for
LOC determination.
Member must be disenrolled
from Hoosier Healthwise and
enrolled in Traditional Medicaid
for the benefit to begin.
For a maximum of 60 days prior to
LOC determination, coverage is
available under managed care.
Coverage includes room and
board, mental health services,
dental services, therapy and
habilitation services, durable
medical equipment, medical
supplies, pharmaceutical products,
transportation, and optometric
services.
Noncovered.
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Benefit Reimbursed
by MCE Package A Package C
Nursing Facility
Services –
Intermediate Care
Facilities for
Individuals with
Intellectual
Disability
(ICFs/IID) –
Short-Term**
(405 IAC 5-31-1)
Yes The MCE may obtain services for
its members in a nursing facility
setting on a short-term basis (fewer
than 30 consecutive calendar
days). This may occur if this
setting is more cost-effective than
other options and the member can
obtain the care and services needed
in the nursing facility. The MCE
can negotiate rates for reimbursing
the nursing facilities for these
short-term stays.
Coverage includes room and
board, mental health services,
dental, therapy and habilitation
services, durable medical
equipment, medical supplies,
pharmaceutical products,
transportation, and optometric
services.
Note: MCEs may be responsible
for payment for up to 60 calendar
days for members placed in a long-
term care facility while the level of
care determination is pending,
allowing the member to be
transitioned to FFS coverage.
Noncovered
Occupational
Therapy*
(405 IAC 5-22)
Yes Occupational therapy services
must be ordered by the member’s
PMP or by another physician as
part of an inpatient discharge plan
of care or continuing plan of care.
Services must be provided by a
licensed therapist or assistant.
PA is not required for initial
evaluations or for services
provided within 30 calendar days
following discharge from a
hospital when ordered by a
physician prior to discharge (not to
exceed 30 units for any
combination of therapies).
Occupational therapy services must
be ordered by the member’s PMP
or by another physician as part of
an inpatient discharge plan of care
or continuing plan of care. Services
must be provided by a licensed
therapist or assistant.
Services are covered only when
determined to be medically
necessary. Maximum of 50 visits
per year (405 IAC 13-7-2), per type
of therapy.
Note: The maximum limit of
therapy visits was removed
for dates of service on or
after January 1, 2020.
Organ
Transplants**
(405 IAC 5-3-13)
Yes Coverage is in accordance with
prevailing standards of medical
care. Similarly situated individuals
are treated alike.
Noncovered
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Benefit Reimbursed
by MCE Package A Package C
Out-of-State
Medical Services**
(405 IAC 5-5)
Yes Coverage is available for the
following services provided
outside Indiana: acute hospital
care, physician services, dental
services, pharmacy services,
transportation services, therapy
services, podiatry services,
chiropractic services, durable
medical equipment, and supplies.
All out-of-state services are subject
to the same limitations as in-state
services.
Coverage is available for the
following services provided outside
Indiana: acute hospital care,
physician services, dental services,
pharmacy services, transportation
services, therapy services, podiatry
services, chiropractic services,
durable medical equipment, and
supplies. Coverage is subject to any
limitations included in the
Package C benefit package.
Physician Surgical
and Medical
Services*
(405 IAC 5-25)
Yes Coverage includes reasonable
services provided by a doctor of
medicine (MD) or doctor of
osteopathy (DO) for diagnostic,
preventive, therapeutic,
rehabilitative, or palliative services
provided within scope of practice.
PMP office visits are limited to a
maximum of 30 per calendar year
per member per provider without
PA.
Coverage includes reasonable
services provided by an MD or DO
for diagnostic, preventive,
therapeutic, rehabilitative, or
palliative services provided within
scope of practice.
PMP office visits are limited to
a maximum of 30 per year per
member without PA.
Physical Therapy*
(405 IAC 5-22-6)
Yes Physical therapy services must be
ordered by the member’s PMP or
by another physician as part of a
member’s inpatient discharge plan
of care or continuing plan of care.
Services must be provided by a
licensed therapist or certified
physical therapist assistant (PTA)
under the direct supervision of a
licensed physical therapist or
physician.
PA is not required for initial
evaluations or for services
provided within 30 calendar days
following discharge from
a hospital when ordered by a
physician prior to discharge (not to
exceed 30 units for any
combination of therapies).
Physical therapy services must be
ordered by the member’s PMP or
by another physician as part of a
member’s inpatient discharge plan
of care or continuing plan of care.
Services must be provided by a
licensed therapist or certified PTA
under the direct supervision of a
licensed physical therapist or
physician.
Services are covered when
determined to be medically
necessary. Maximum of 50 visits
per year, per type of therapy.
Note: The maximum limit of
therapy visits was removed
for dates of service on or
after January 1, 2020.
Podiatric Services
(405 IAC 5-26)
Yes
(Self-referral)
Laboratory services, x-ray
services, hospital stays, and
surgical procedures involving the
foot are covered when medically
necessary. No more than six
routine foot care visits per year are
covered.
Laboratory services, x-ray services,
hospital stays, and surgical
procedures involving the foot are
covered when medically necessary.
Routine foot care services are not
covered.
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Benefit Reimbursed
by MCE Package A Package C
Psychiatric
Residential
Treatment Facility
(PRTF) **
(405 IAC 5-20-3.1)
No Reimbursement is available for
medically necessary services
provided to members younger than
21 years old in a PRTF.
Reimbursement is also available
for members younger than 22 years
old who began receiving PRTF
services immediately before their
21st birthday.
Member must be disenrolled
from Hoosier Healthwise
and enrolled in Traditional
Medicaid for the benefit to
begin.
The FSSA will notify the MCE
when an MCE’s member is
admitted to a PRTF. The MCE
is required to provide case
management and utilization
management during the member’s
stay. The MCE is not at financial
risk for PRTF services.
Reimbursement is available for
medically necessary services
provided to members younger than
21 years old in a PRTF.
Member must be disenrolled
from Hoosier Healthwise
and enrolled in Traditional
Medicaid for the benefit to begin.
The FSSA will notify the MCE
when an MCE’s member is
admitted to a PRTF. The MCE
is required to provide case
management and utilization
management during the member’s
stay. The MCE is not at financial
risk for PRTF services.
Rehabilitation Unit
Services –
Inpatient**
(405 IAC 5-32)
Yes The following criteria shall
demonstrate the inability to
function independently with
demonstrated impairment:
cognitive function,
communication, continence,
mobility, pain management,
perceptual motor function, or
self-care activities.
Covered up to 50 days per calendar
year.
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Benefit Reimbursed
by MCE Package A Package C
Respiratory
Therapy*
(405 IAC 5-22)
Yes Respiratory therapy services must
be ordered by the member’s PMP
or by another physician as part of a
member’s inpatient discharge plan
of care or continuing plan of care
and provided by a licensed
respiratory therapist or certified
respiratory therapy technician who
is an employee or contractor of a
hospital, medical agency, or clinic.
PA is not required for inpatient or
outpatient hospital, emergency,
and oxygen in a nursing facility,
for 30 calendar days following
discharge from hospital when
ordered by physician prior to
discharge (not to exceed 30 units
for any combination of therapies),
and when ordered in writing for the
acute medical diagnosis of asthma,
pneumonia, bronchitis, or upper
respiratory infection (not to exceed
14 hours or 14 calendar days).
Respiratory therapy services must
be ordered by the member’s PMP
or by another physician as part of a
member’s inpatient discharge plan
of care or continuing plan of care
and provided by a licensed
respiratory therapist or certified
respiratory therapy technician who
is an employee or contractor of a
hospital, medical agency, or clinic.
Services are covered when
determined to be medically
necessary. Maximum of 50 visits
per year (405 IAC 13-7-2), per type
of therapy.
Note: The maximum limit of
therapy visits was removed
for dates of service on or
after January 1, 2020.
Rural Health
Clinics (RHCs)
Yes Coverage is available for services
provided by a physician; physician
assistant; nurse practitioner; or
appropriately licensed, certified, or
registered therapist employed by
the RHC.
Coverage is available for services
provided by a physician; physician
assistant; nurse practitioner; or
appropriately licensed, certified, or
registered therapist employed by
the RHC.
Speech, Hearing
and Language
Disorders*
(405 IAC 5-22)
Yes Speech-language therapy services
must be ordered by the member’s
PMP or by another physician as
part of a member’s inpatient
discharge plan of care or
continuing plan of care and
provided by a qualified therapist or
assistant.
PA is not required for initial
evaluations or for services
provided within 30 calendar days
following discharge from a
hospital when ordered by physician
prior to discharge (not to exceed 30
units for any combination of
therapies).
Speech-language therapy services
must be ordered by the member’s
PMP or by another physician as
part of a member’s inpatient
discharge plan of care or
continuing plan of care and
provided by a qualified therapist or
assistant.
Services are covered when
determined to be medically
necessary.
Maximum of 50 visits per year, per
type of therapy.
Note: The maximum limit of
therapy visits was removed
for dates of service on or
after January 1, 2020.
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Benefit Reimbursed
by MCE Package A Package C
Tobacco
Dependence
Treatment
(405 IAC 5-37)
Yes
(Except
pharmacy
benefits)
Reimbursement is available for
tobacco dependence drug treatment
and counseling services. Coverage
of tobacco dependence counseling
is limited to a maximum of 10
units per member per calendar
year.
Reimbursement is available for
tobacco dependence drug treatment
and counseling services. Coverage
of tobacco dependence counseling
is limited to a maximum of 10
units per member per calendar
year.
Transportation –
Emergency
(405 IAC 5-30)
Yes Coverage has no limit or prior
authorization requirement for
emergency ambulance or trips to or
from a hospital for inpatient
admission or discharge, subject to
the prudent layperson standard.
Covers emergency ambulance
transportation using the prudent
layperson standard. A $10
copayment applies.
Transportation –
Nonemergency
(405 IAC 5-30)
Yes Nonemergency travel is available
for up to 20 one-way trips of less
than 50 miles per year without PA.
Ambulance services for
nonemergencies between medical
facilities are covered when
requested by a participating
physician; a $10 copayment
applies. Any other nonemergency
transportation is not covered.
Urgent Care
Services
Yes
(Self-referral)
Urgent care services are covered
provided that they are medically
necessary. Urgent care is needed
for non-life-threatening
emergencies that cannot wait for a
normal scheduled office visit.
Urgent care services are covered
provided that they are medically
necessary. Urgent care is needed
for non-life-threatening
emergencies that cannot wait for a
normal scheduled office visit.
* Prior authorization required under certain circumstances
** Prior authorization always required
Note: In general, all noncontracted, out-of-network providers require PA. Contracted, in-network providers
must contact the MCE to determine whether PA is required.
Program of All-Inclusive Care for the Elderly
The Program of All-Inclusive Care for the Elderly (PACE) is a risk-based managed care Medicare and
Medicaid program that serves individuals who:
Are 55 years old or older
Are certified by their state to need nursing home care
Are able to live safely in the community at the time of enrollment
Live in a PACE service area (Contact local Area Agency on Aging [AAA] for guidelines.)
PACE participants are required to sign an enrollment agreement indicating they understand that the PACE
organization must be their sole service provider. Services must be preapproved or obtained from specified
doctors, hospitals, pharmacies, and other healthcare providers that contract with the PACE organization.
Before providing services to a member, IHCP providers should always check the member’s Medicare or
IHCP card for a sticker indicating that the member is a PACE participant. The IHCP will deny payment of
all fee-for-service claims submitted for PACE members.
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PACE benefits include the following:
Primary care
Hospital care
Medical specialty services
Prescription drugs
Nursing home care
Emergency services
Home care
Physician, occupational, and recreational therapy
Adult day care
Meals
Dentistry
Nutritional counseling
Social services
Laboratory/x-ray services
Social work counseling
Transportation
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Section 4: Special Programs and Processes
The Indiana Health Coverage Programs (IHCP) offers a variety of special programs and processes designed
to serve special populations.
Presumptive Eligibility
Presumptive Eligibility (PE) is an authorized IHCP process by which qualified providers (QPs) can
determine individuals to be presumptively eligible, allowing them to receive temporary health coverage
until the Family and Social Services Administration (FSSA) determines official eligibility.
For more information about PE process, including how to become a QP, see the Presumptive Eligibility
module.
Presumptive Eligibility Coverage Period
The PE coverage period begins on the day the QP determines an individual presumptively eligible for
coverage. Services delivered prior to this date are not covered. For presumptive eligibility benefit plans that
include inpatient hospital coverage:
If a hospital admission date is before the presumptive eligibility start date, and the inpatient service
is reimbursed using the diagnosis-related group (DRG) methodology, no portion of that member’s
inpatient stay will be considered a presumptive-eligibility-covered service.
If a hospital admission date is before the presumptive eligibility start date, and the inpatient service
is reimbursed on a level-of-care (LOC) per diem basis, dates of service on or after the member’s
presumptive eligibility start date will be covered.
If the PE member submits a completed Indiana Application for Health Coverage before the end of the
month following the month in which his or her PE coverage began, then the PE coverage will last until the
FSSA makes an official eligibility determination. PE coverage ends immediately when the FSSA
determines the applicant to be denied for IHCP coverage. If determined eligible, PE coverage continues
through the end of the month the eligibility decision is made.
If a PE member does not have a completed Indiana Application for Health Coverage pending with the
FSSA by the last day of the month following the month in which his or her PE was established, the PE
coverage will end on that date.
General Requirements for Presumptive Eligibility
General applicant requirements for PE are as follows:
Must be a U.S. citizen, qualified noncitizen, or a qualifying immigrant with one of the following
immigration statuses:
– Lawful permanent resident immigrant living lawfully in the United States for 5 years or longer
– Refugee
– Individual granted asylum by immigration office
– Deportation withheld by order from an immigration judge
– Amerasian from Vietnam
– Veteran of U.S. Armed Forces with honorable discharge
– Other qualified alien
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Must be an Indiana resident
– An Indiana address must be provided on the application.
Must not be a current IHCP member, including a member of HIP*
– Medical Review Team (MRT) and Preadmission Screening and Resident Review (PASRR)
coverage are the only exceptions to this requirement; members with coverage under any other
benefit plan are not eligible for PE.
– Individuals who have recently applied for the IHCP but have not yet received a coverage
determination may apply for PE to cover services while an IHCP decision is pending.
Must not be enrolled in the PE process, currently or within time-frame restrictions*
– Individuals are allowed only one PE coverage period per rolling 12 months (or per pregnancy,
for Presumptive Eligibility for Pregnant Women).
Must not be currently incarcerated*
Must not be an adult (ages 21–64) who is admitted to or residing in an institute for mental disease
(IMD)
Must meet the income level, age, and any other requirements specific to certain aid categories
*Note: For exceptions specific to inmates, see the Presumptive Eligibility for Inmates section.
Presumptive Eligibility Aid Categories and Benefit Plans
Aid categories eligible for PE include:
Infants (under 1 year of age)
Children (ages 1–18)
Parents/caretakers
Adults (ages 19–64, without Medicare)
Pregnant women
Former foster care children (ages 18–25)
Individuals eligible for family planning services only
For details about income limits and other requirements specific to each aid category, see the
Presumptive Eligibility module.
The benefit plan assigned during the PE period depends on the individual’s aid category (with the
exception of Medicaid Inpatient Hospital Services Only, which is assigned to presumptively eligible
inmates regardless of their aid category). All presumptive eligibility benefit plans are provided under the
fee-for-service (FFS) delivery system.
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Table 9 – Presumptive Eligibility Benefit Plans and Coverage
PE Aid Category Benefit Plan Coverage Details
Infants
Presumptive Eligibility –
Package A Standard Plan
All services available under Package A –
Standard Plan (Medicaid State Plan
services)
Children
Parents/caretakers
Former foster care children
Pregnant women Presumptive Eligibility for
Pregnant Women
Ambulatory prenatal care services only
(See the Presumptive Eligibility module
for details.)
Individuals presumptively
eligible for family planning
benefits only
Presumptive Eligibility Family
Planning Services Only
Only services available under the Family
Planning Eligibility Program
(See the Family Planning Eligibility
Program section for details.)
Adults not eligible for another
category Presumptive Eligibility – Adult
Only services available under Healthy
Indiana Plan (HIP) Basic, including
copayment obligations
(See the Healthy Indiana Plan section
for details.)
PE for Inmates Benefit Plan Coverage Details
Incarcerated individuals who
are presumptively eligible,
regardless of PE aid category
Medicaid Inpatient Hospital
Services Only
Only inpatient services
(See the Presumptive Eligibility for
Inmates section for details)
Presumptive Eligibility for Inmates
Presumptive Eligibility for Inmates (PE for Inmates) allows acute care hospitals that are PE QPs to enroll
eligible inmates into the IHCP for temporary coverage of authorized inpatient hospitalization services.
Coverage during the PE for Inmates period is identified as Medicaid Inpatient Hospital Services Only.
Requirements for PE for Inmates
In addition to meeting all the general applicant requirements for PE (with the exception of requirements
pertaining to incarceration, current IHCP coverage, and current or past PE coverage, as indicated in the
General Requirements for Presumptive Eligibility section), individuals found presumptively eligible
through the PE for Inmates process must also meet the following additional requirements:
Be an inmate from an Indiana Department of Correction (IDOC) facility or county jail operating
under the memorandum of understanding or contract with the Indiana Family and Social Services
Administration (FSSA)
Not be on house arrest (individuals under house arrest may be eligible under the regular PE process)
Not be pregnant or admitted for labor and delivery
Be admitted for inpatient hospitalization
Be under the age of 65
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Coverage under PE for Inmates
The Medicaid Inpatient Hospital Services Only benefit plan provides coverage for inpatient services only.
If an inmate’s admission results from an emergency department visit, the physician services performed in
the emergency department prior to admission can be reimbursed. In all other cases, services can be
reimbursed only if they are provided between inpatient admission and discharge. The following are
examples of services that may be covered for inmates hospitalized for at least 24 hours:
Medically necessary physician services provided during the inpatient stay
Medically necessary hospital services provided during the inpatient stay
Medically necessary medications provided during the inpatient stay
Medically necessary durable medical equipment (DME) provided during the inpatient stay
Any service provided on an outpatient basis, before inpatient admission or after discharge, will not be
reimbursed. The following are examples of services that are not covered:
Transportation that occurs before admission or after discharge
Services provided in the emergency department if the visit does not result in an inpatient admission
Medications or DME that are provided before inpatient admission or after discharge
For special billing instructions related to the Medicaid Inpatient Hospital Services Only benefit plan, see
the Claim Submission and Processing module.
Extended PE Coverage Period for Inmates
To retain inpatient benefits, inmates who go through the PE process must complete an Indiana Application
for Health Coverage, with assistance from the correctional facility or county jail. Individuals who complete
the full application and are confirmed eligible for PE for Inmates will continue to be covered under the
Medicaid Inpatient Hospital Services Only benefit plan for 12 months. If the inmate does not complete an
Indiana Application for Health Coverage, his or her Medicaid Inpatient Hospital Services Only coverage
will end on the last day of the month following the month in which the individual was found presumptively
eligible. If the individual remains incarcerated after 1 year, he or she may reapply for coverage through the
PE for Inmates process.
Medical Review Team
Individuals determined by the Social Security Administration to be disabled are considered disabled for
Medicaid purposes. For all others, the DFR is responsible for determining initial and continuing eligibility
for Medicaid disability. To meet the disability requirement, a person must have an impairment that is
expected to last a minimum of 12 months.
The Medical Review Team (MRT) determines whether an applicant meets the Medicaid disability
definition based on medical information that the DFR collects and provides to the MRT.
Note: An individual receiving Supplemental Security Income (SSI) or Social Security
Disability Income (SSDI) for his or her own disability automatically meets the State’s
disability requirement without requiring a separate disability determination by MRT.
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To make timely determinations about an applicant’s alleged disability for coverage through the IHCP, the
MRT directs providers to include medical reports that substantiate level of severity and functionality. The
following examples represent expected information for the four most common application diagnoses:
Back pain
– Associated surgeries for back pain
– Medications that the applicant is taking
– Details about the applicant’s level of functioning with the back pain
– Any additional information about the applicant’s back pain
Depression
– Associated hospitalizations for depression
– Medications the applicant is taking
– Details about the applicant’s level of functioning with depression
– Any additional information about the applicant’s depression
Diabetes
– Associated neuropathy, nephropathy, or retinopathy
– Blood sugar levels, HgA1C levels, and other relative lab results
– Medications the applicant is taking
– Diabetes flow sheet
– Details about the applicant’s level of functioning with diabetes
– Additional information about the applicant’s diabetes
Hypertension
– Associated end organ damage due to hypertension
– Medications the applicant is taking
– Details about the applicant’s level of functioning with hypertension
– Any additional information about the applicant’s hypertension
See the Claim Submission and Processing module for MRT billing procedures.
Right Choices Program
The Right Choices Program (RCP) is Indiana’s Restricted Card Program. The goal of the RCP is to provide
quality care through healthcare management, ensuring that the right service is delivered at the right time
and in the right place for Healthy Indiana Plan (HIP), Hoosier Care Connect, Hoosier Healthwise, and
Traditional Medicaid members who have been identified as using services more extensively than their
peers. RCP members remain eligible to receive all medically necessary, covered services allowed by their
existing benefit plans. However, services are reimbursed only when rendered by the member’s assigned
RCP lock-in providers or when rendered by a specialist who has received a valid, written referral from the
member’s primary RCP physician. See the Right Choices Program module for details about the RCP.
Note: The Provider Healthcare Portal eligibility verification includes a Right Choices
Detail panel for members assigned to the RCP. Users can expand this detail panel to
view lock-in provider assignments.
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Preadmission Screening and Resident Review
The Preadmission Screening and Resident Review (PASRR) process is a requirement for all residents of
IHCP-certified nursing facilities. The screening identifies individuals who may have a mental illness (MI),
intellectual disability/developmental disability (ID/DD), or mental illness and intellectual
disability/developmental disability (MI/ID/DD).
PASRR coverage is identified in the EVS as PASRR Mental Illness (MI) or PASRR Individuals with
Intellectual Disability (IID). Only providers contracted with the Division of Mental Health and Addiction
(DMHA) or the Division of Disability and Rehabilitative Services (DDRS) can be reimbursed for PASRR
services.
See the Long-Term Care module for more information about the PASRR process.
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Section 5: Member Copayment Policies
Note: For specific copayment policies regarding services rendered to members enrolled in
managed care plans, providers should contact the appropriate managed care entity
(MCE). MCE contact information is included in the IHCP Quick Reference Guide
available at in.gov/medicaid/providers.
Overview
Some Indiana Health Coverage Programs (IHCP) members are required to contribute a copayment for
certain services. The copayment is made by the member and collected by the provider at the time the
service is rendered. The amount of the copayment is automatically deducted from the provider’s payment;
therefore, the provider should not subtract the copayment from the submitted charge.
According to Code of Federal Regulations 42 CFR 447.15, providers may not deny services to any member
due to the member’s inability to pay the copayment amount on the date of service. Pursuant to this federal
requirement, this service guarantee does not apply to a member who is able to pay, nor does a member’s
inability to pay eliminate his or her liability for the copayment. It is the member's responsibility to inform
the provider that he or she cannot afford to pay the copayment on the date of service. The provider may bill
the member for copayments not paid on the date of service.
For fee-for-service (FFS) members, providers can determine the copayment amount due for a particular
service on a particular date when verifying the member’s eligibility through any of the Eligibility
Verification System (EVS) options: Provider Healthcare Portal (Portal), 270/271 electronic transactions, or
Interactive Voice Response (IVR) system. See the Portal Copayment Response section for examples of
how the information appears on the Portal.
Copayment Limitations and Exemptions
In accordance with federal regulations, IHCP members with cost-sharing obligations (such as copayments,
contributions, premiums, deductibles, or other Medicaid-related charges) are not required to pay more than
5% of the family’s total countable income toward these charges. The 5% calculation considers the total cost-
sharing amounts paid by all members in the household against the total countable income for the household.
The IHCP applies this limit based on calendar quarters: January–March, April–June, July–September, and
October–December. (For Package C members, the 5% limitation applies on a yearly basis.)
Accordingly, copayment amounts will not be deducted from claims processed after the member’s
copayment obligation has been met in any given quarter. If a member’s copayment obligation has been met
for the quarter for fee-for-service (FFS) benefits, a copayment amount of $0 will be indicated in the EVS
for the member on that date of service. See the Portal Copayment Response section for an example. (For
managed care benefits, providers will need to contact the MCE to determine whether the member’s
copayment obligation has been met for the quarter.)
Members in the following categories are exempt from cost-sharing obligations, including copayments:
American Indian/Alaskan Native
Under age 18, except for Package C members
Pregnant
Receiving hospice care
Eligible for Medicaid due to a diagnosis of breast or cervical cancer
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Note: Members residing in an institution are exempt from copayment obligations but are
responsible for paying any applicable facility liability.
Members in exempt categories are not affected by the cost-sharing tracking process – they should never be
charged copayments.
Service-Specific Copayment Policies
Providers are advised to review the Indiana Administrative Code (IAC) for complete copayment narratives.
The following services may require a copayment:
Transportation (405 IAC 5-30-2)
Pharmacy (405 IAC 5-24-7)
Nonemergency services provided in an emergency room setting (405 IAC 1-8-4)
Additional services are subject to copay under certain Healthy Indiana Plan (HIP) benefit plans, as
described in the Personal Wellness and Responsibility Account and Copayments section. Presumptive
Eligibility Adult copayments mirror those of HIP Basic.
Table 10 provides copayment amounts at a glance for specific services provided to Traditional Medicaid,
Hoosier Care Connect, and Hoosier Healthwise Package C members. The sections that follow provide
additional information.
Table 10 – Service-Specific Copayments by Program
Traditional Medicaid
(Fee for Service) Hoosier Care Connect
Hoosier Healthwise
(Package C Only)
Nonemergency
transportation
$0.50–$2 each way $1 each way Noncovered
Emergency
transportation
No copay No copay $10
Pharmacy (generic) $3 per prescription $3 per prescription $3 per prescription
Pharmacy (brand name) $3 per prescription $3 per prescription $10 per prescription
Nonemergency use of
the emergency room
No copay $3 No copay
Section 5: Member Copayment Policies Member Eligibility and Benefit Coverage
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Transportation Services
For nonemergency transportation services, providers may collect a copayment from Traditional Medicaid
members equal to the amount presented in Table 11.
Table 11 – Nonemergency Transportation Copayments for Traditional Medicaid
Copayment Service
$0.50 each one-way trip Transportation services for which Medicaid pays $10 or less
$1 each one-way trip Transportation services for which Medicaid pays $10.01 to $50
$2 each one-way trip Transportation services for which Medicaid pays $50.01 or more
Note: The determination of the member’s copayment amount is to be based on the
reimbursement for the base rate or loading fee only.
No copayment is required for an accompanying adult (such as a parent) traveling with a
minor member or for an attendant.
The nonemergency transportation copayment for Hoosier Care Connect members is $1 each one-way trip,
regardless of distance.
For both Traditional Medicaid and Hoosier Care Connect members, emergency ambulance services are
exempt from copayments.
Hoosier Healthwise Package C members receive ambulance transportation services, subject to a $10
copayment, in the following circumstances:
Emergencies, subject to the prudent layperson definition of emergency in 405 IAC 11-1-6
Between medical facilities when ordered by the treating physician
All other transportation is not a covered service under Package C.
Pharmacy Services
Traditional Medicaid and Hoosier Care Connect members are generally required to pay a $3 copay for all
prescription drugs. Pharmacy copayments for Package C members are $3 for generic drugs and $10 for
brand name drugs.
For more detailed information about copayments for pharmacy services, see the Pharmacy Services module.
Nonemergency Services Rendered in the Emergency Department
Hoosier Care Connect members are subject to a copayment of $3 per date of service for nonemergency
services rendered in an emergency department setting.
Family planning services are exempt from the copayment requirements for nonemergency services
rendered in an emergency department.
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Portal Copayment Response
On the Portal, copayment information is displayed in the Benefit Details panel (see Figure 25).
Figure 25 – Copayment Information in the Portal
When the member has met the quarterly cost-sharing obligation, the amount indicated in the Copay
Amount column will change to $0.00.
The copay amount may also display $0.00 in situations where the amount owed is a range or when
providers are required to check with the MCE for the specific amount of the copay. In these cases, the
presence of a zero in the last column does not necessarily indicate that the member’s cost-sharing
obligation has been met. See Figure 26.
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Figure 26 – Portal Response for Managed Care Benefit Plans That May Require a Copay
If a member’s benefit plan does not require copayments, the Portal message will indicate that copayments
do not apply (see Figure 27).
Figure 27 – Portal Response for Benefit Plans That Do Not Require Copays
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Section 6: Benefit Limit Information
Note: The information in this section pertains to fee-for-service coverage. For managed
care members, providers must follow the managed care entity (MCE) procedures for
obtaining benefit limit information.
Some Indiana Health Coverage Programs (IHCP) services are subject to benefit limits, based on the
number of units or dollar amount reimbursed within a given time frame. Before rendering such services,
providers must verify that the member’s benefit limit has not been met.
For details about service-specific benefit limits, refer to the provider reference module applicable to that
type of service.
Checking Benefit Limits on the EVS
Select member benefit limit information is available through Eligibility Verification System (EVS), which
providers can access through any of the following methods, as described in the Eligibility Verification
System section:
Provider Healthcare Portal, accessible from the home page at in.gov/medicaid/providers
Interactive Voice Response (IVR) system at 1-800-457-4584
270/271 electronic data interchange (EDI) transaction
The EVS response consists of a description of the limit (including the applicable explanation of benefits
[EOB] code that would be returned with claim denials if the limit is exceeded), what the limit is (the dollar
amount or number of units allowed for the particular service within the given time frame), and how much is
remaining for that member. The amount remaining reflects FFS paid claims only, and does not include
payment for claims that are still in process.
See Figure 28 for an example of the benefit limits returned using the Portal.
Figure 28 – Benefit Limit Details on the Portal
The system lists only services for which some reimbursement has been made. If the full amount is still
remaining for a particular limit, that limit will not be displayed.
Not all benefit limits are tracked within the EVS. See Table 12 for a list of those limits that are returned by
the EVS, as well as the associated EOB that would be returned if additional amounts were billed after the
limit has been met. To avoid claim denials for the EOBs shown in Table 12, before rendering such services,
providers should use the EVS to verify that the member has not exhausted the applicable benefit limits.
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Table 12 – EOBs Related to Benefit Limit Information Available through the EVS
Limit Description Corresponding EOB Description
6012 MEDICAL SERVICES 30 PER YEAR Reimbursement is limited to 30 medical services per
member per rolling calendar year, unless prior
authorization for additional services has been
obtained.
6054 ONLY ONE HEARING TEST PER 36 MO.
WITHOUT PA
Audiological assessments are limited to once every 3
years per member. Prior authorization is required for
payment of additional services
6060 SPEECH THERAPY EVALUATIONS/ONE
PER YEAR
Reimbursement for speech evaluation is limited to
once every twelve months. Prior authorization is
required for payment of additional evaluations.
6085 INCONTINENCE SUPPLIES LIMITED
$1950/ROLLING YEAR
Incontinence supplies are limited to total dollar
amount of $1,950.00 per rolling 12 months
6090 PODIATRIST OFFICE VISITS LTD TO 1
PER 12 MO (DTL)
Indiana Medicaid benefits allow payment for one (1)
podiatry office visit per recipient per calendar year.
6099 REIMBURSEMENT IS LIMITED TO 50
CHIROPRACTIC SVCS
Reimbursement is limited to no more than 50
chiropractic services per member per calendar year.
These services could include up to five (5) office
visits and spinal manipulation treatments, or physical
medicine treatments.
6101 CHIROPRACTIC RESTRICTIVE OFFICE
VISITS CODES (NP)
New patient chiropractic office visits are
reimbursable once per provider per lifetime of the
recipient.
6102 CHIROPRACTIC OFFICE VISITS LIMITED
TO 5 PER YEAR
Indiana Heath Coverage Programs reimbursement
limited to five chiropractic office visits per year. This
recipient has received the maximum number
allowable. Prior authorization is required for
payment of additional visits.
6105 ONE FULL SPINE X-RAY PER YEAR FOR
CHIROPRACTOR
Indiana Health Coverage Program reimbursement is
limited to one (1) full spinal x-ray per recipient per
calendar year by a chiropractor. Maximum
reimbursement has been paid. Prior authorization is
required for payment of additional visits.
6111 CHIROPRACTIC OFFICE VISITS LIMITED
TO FIVE PER YEAR
Reimbursement is limited to five chiropractic office
visits per year per member. This member has
received the maximum number allowable.
6112 MAX OF 14-CHIRO THERAPEUTIC PHYS
MED TRT PER YR
Therapeutic physical medicine treatments are limited
to 14 per member per calendar year. This member
has received the maximum number allowable.
6113 DME LIMITED TO $2000 PER MEMBER
PER CAL YR
Durable medical equipment is limited to $2,000 per
member per calendar year. This member has
received the maximum amount allowable
6114 DME LIMITED TO $5000 PER MEMBER
PER LIFETIME
Reimbursement for durable medical equipment is
limited to $5,000 per member per lifetime.
6115* PHYS THERAPY SVCS LIMIT 50 VISITS
PER YR
Reimbursement is limited to 50 physical therapy
treatments per member per calendar year. This
member has received the maximum number
allowable.
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Limit Description Corresponding EOB Description
6116* SPEECH THERAPY SVC LIMIT 50 VISITS
PER YR
Reimbursement is limited to 50 speech therapy
treatments per member per calendar year. This
member has received the maximum number
allowable.
6118* OT SVCS LTD TO 50 VISITS PER CAL YR Reimbursement is limited to 50 occupational therapy
treatments per member per calendar year. This
member has received the maximum number
allowable.
6119* INPT REHAB SVCS LIMIT 50 DAYS PER
CALENDA
Reimbursement is limited to 50 days of inpatient
rehabilitation services per recipient per calendar
year. This recipient has received the maximum
number allowable.
6120 OP MNTL HLTH/SUBS ABUSE OV 30 /
CAL YR W/O PA (DTL)
Reimbursement is limited to 30 visits for outpatient
mental health/substance abuse services per recipient
per calendar year without prior authorization. This
recipient has received the maximum number
allowable.
6121 OP MNTL HLTH/SUBS ABUSE OV 50 /
CAL YR W/PA (DTL)
Reimbursement is limited to 50 visits maximum for
outpatient mental health/substance abuse services per
recipient, per calendar year, with prior authorization.
This recipient has received the maximum number
allowable.
6122 CHIROPRACTIC THERAPEUTIC
PHYSICAL MEDICINE TREATME
Therapeutic physical medicine treatments exceeding
fourteen (14), up to a maximum of fifty (50), per
recipient, per calendar year, require prior
authorization.
6195 FRAMES INITIAL OR REPAIR /
REPLACEMENT 21 YRS OLDER
Frames initial or repair/replacement- member over
21 years of age
6196 FRAMES INITIAL / REPLACEMENT
MEMBER 21 YRS YOUNGER
Frames initial or replacement- member 21 years or
younger
6209 FULL MOUTH OR PANORAMIC X-RAYS
LIMIT ONCE /3 YRS
Full-mouth or panorex x-rays limited to once every
three years.
6211 PERIODIC/LIMITED ORAL EVAL LIMIT 1
EVERY 6 MONTHS
Periodic or limited oral evaluations are limited to one
every 6 months.
6212 FLUORIDE TREATMENT LIMITED TO 1
EVERY 6 MONTHS
Indiana Health Coverage Program benefits allow
payment for one topical application of fluoride every
six (6) months. Fluoride treatments are limited to
recipients 0 through 20 years of age.
6221 PERIODONTAL ROOT PLAN/SCAL 4
TX/2YRS NON-INSTITUTI
Reimbursement limited to four treatments of
periodontal root planing/scaling every two (2) years
for non-institutionalized recipients between the ages
of three (3) and twenty (20) years.
6222 PERIODONTAL ROOT PLAN/SCALING, 4
TX PER 2 YRS INST
Reimbursement is limited to four treatments of
periodontal root planing and scaling for
institutionalized recipients every two (2) years
regardless of age.
6223 PERIODONTAL ROOT PLAN 21 YR
OR > 4/LIFE NON-INST
Periodontal root planing/scaling 4x/lifetime/non-
institutional 21 years and older.
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Limit Description Corresponding EOB Description
6225 ONE SEALANT PER TOOTH PER
LIFETIME
Indiana Health Coverage Program benefits allow
payment for one sealant treatment per premolars and
molars per lifetime.
6235 PROPHY & PERIODTL MAINT NON-INSTI
21> LIM 1/12 MOS
Prophylaxis and periodontal maintenance is limited
to one treatment every 12 months for non-
institutional members 21 years or older.
6244 D4355 LIMITED TO ONCE EVERY 3
YEARS (DTL)
D4355 [full mouth debridement to enable
comprehensive evaluation and diagnosis] limited to
once every 3 years.
6271 LENSES INITIAL/REPLACEMENT,
MEMBER YOUNGER THAN 21
Lenses initial or replacement- member 21 year or
younger
6272 LENSES INITIAL REPAIR/REPLACEMENT
MEMBER 21 YRS
Lenses initial repair/replacement member over 21
years of age
6297 ROUTINE VISION EXAM LIMIT TO 1/12
MONTHS AGE 0-20
Routine vision exams limited to one (1) per twelve
(12) months for ages 1 to 20 years.
6298 ROUTINE VISION EXAM AGE 21-999 LTD
TO 1/24 MO (DTL)
Routine vision exams are limited to one (1) per
twenty-four (24) months for ages twenty-one to 999
years.
6310 PROPHY & PERIODTL MAINT NON-INSTI
1-20 LIM 1/6 MOS
Prophylaxis and periodontal maintenance limited to
one treatment every six months for non-
institutionalized members over age twelve months to
twenty-one years
6752 PT EVAL LTD TO 1 PER 12 MO W/O
APPROVED PA (DTL)
Reimbursement is limited to one physical therapy
evaluation per member per 12 months unless prior
authorization has been obtained.
6753 OCCUPATIONAL THERAPY
EVALUATION - 1 PER 12 MONTHS
Reimbursement is limited to one occupational
therapy evaluation per member per 12 months unless
prior authorization has been obtained.
6803 TRANSPORT: ONE-WAY TRIP IN EXCESS
OF 20/12 MONTHS
Prior authorization required for transportation
services in excess of the allowed number minus
exemptions.
6855 MORE THAN 6 ROUTINE FOOT CARE
TREATMENTS/12 MONTHS
Reimbursement is limited to six routine foot care
services per year for patients with diabetes mellitus,
peripheral vascular disease, or peripheral neuropathy,
unless prior authorization has been obtained.
*Note: Limits marked with an asterisk will no longer be applied for dates of service on or after
January 1, 2020.
Checking Benefit Limits via Written Correspondence
Not all benefit limits are tracked by the EVS. Additionally, the EVS may not include all the information
that a provider needs to determine whether a member has exhausted a particular benefit – such as the dates
the limits were exhausted. This situation can result in reduced reimbursement or no reimbursement for
rendered services. Providers may submit secure correspondence through the Portal to inquire the date on
which a particular member exceeded his or her service limitations. Providers should allow up to 4 business
days for a response.
Section 6: Benefit Limit Information Member Eligibility and Benefit Coverage
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To assist analysts in researching the issue and providing a resolution, providers should clearly state the
reason for the inquiry. The Written Correspondence Unit may contact the provider for additional
information if needed.
Providers should not send inquiries to resubmit claims previously rejected.
To submit an inquiry through the Portal, providers can create a secure correspondence message using
the Coverage Inquiry category. For information about registering to use the Portal and submitting secure
correspondence via the Portal, see the Provider Healthcare Portal module.
Calendar-Year Versus 12-Month Monitoring Cycle
Most IHCP benefit limits are monitored via a rolling 12-month period. However, some are monitored on a
calendar-year basis. During claim processing, CoreMMIS reviews the claim history to ensure that services do
not exceed established limits. CoreMMIS compares the service date for a particular claim with service dates
that are already paid. CoreMMIS looks back at service dates within the particular code’s established service
limit. If the number of services or dollars has been exceeded for a specific benefit limit, prior authorization
(PA) may be required based on medical necessity. If PA is not obtained, CoreMMIS rejects the claim. In
summary, CoreMMIS generally rolls back 1 year from the service date and counts the number of units or
dollars used. CoreMMIS calculates benefit limits on a service-date-specific basis for paid claims.
Example 1: This example illustrates a calendar-year monitoring cycle. IHCP members are authorized office
visits at 30 per calendar year. A member became eligible on February 1, 2019, and with four office visits
per month (to a physician, chiropractor, podiatrist, and mental health provider), reaches the 30-office-visit
limitation in September 2019. Without PA, the member is not authorized for another office visit until
January 1, 2020 (the beginning of a new calendar year), at which point the restriction of 30 visits per
calendar year is restored.
Example 2: This example illustrates a rolling 12-month monitoring cycle. The IHCP limits coverage of
mental health services provided in an outpatient or office setting to 20 units per member, per provider, per
rolling 12-month period without prior authorization. A member became eligible on February 1, 2019, and
received four units of outpatient mental health services on the first day of eligibility. On September 1, 2019,
the member reached the 20-unit limitation. Without PA, the member is not authorized for another outpatient
mental health service until February 1, 2020. In this example of a 12-month limitation, the system restores
the four units depleted on September 1, 2019, 12 months (or 365 days) after the date they were used. In this
illustration, if the member does not use another outpatient mental health service until all 20 units are restored,
the full complement of 20 units per rolling 12-month period would be totally restored in September 2020.
The following services are limited on a calendar-year basis:
Office visits
Inpatient rehabilitation
Durable medical equipment (DME) and home medical equipment (HME)
Chiropractic
Vision
The following services are limited on a rolling 12-month basis:
Mental health visits
Transportation
Incontinence supplies
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Billing Members for Services that Exceed Benefit Limits
Providers may bill IHCP members for services exceeding the benefit limitations under the following
circumstances:
If the EVS indicates that the limitation has already been met, the provider should inform the
member that the service will not be covered. If the member still wishes to receive the service, he or
she may be asked to sign a waiver stating the service will not be covered because benefits have been
exhausted and the member will be responsible for the charges.
If the EVS does not indicate that benefits have been exhausted, the provider may ask the member or
their guardian to attest in writing that they have not received the service in question within the
applicable timeframe. The member is informed that, if he or she is misrepresenting and
the provider’s claim is denied for exceeding benefit limitations, the member will be responsible for
the charges.
See the Charging Members for Noncovered Services section of the Provider Enrollment module for more
information.
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Section 7: Retroactive Member Eligibility
For many Indiana Health Coverage Programs (IHCP) members, eligibility may be established retroactively
up to 3 months prior to the member’s date of application, if the member met eligibility requirements in each
of those retroactive months.
Exceptions include:
Healthy Indiana Plan (HIP) members (other than HIP Maternity members) – Contact the member’s
managed care entity (MCE) for more information.
Hoosier Healthwise Package C members – See the Limited Retroactive Eligibility for Hoosier
Healthwise Package C Members section for more information.
Qualified Medicaid Beneficiary (QMBs benefits – Eligibility is effective no earlier than the month
of application.
For these members, eligibility is effective no earlier than the month of application.
Retroactive Eligibility for Managed Care Members
IHCP applicants determined eligible for Hoosier Care Connect, Hoosier Healthwise Package A, or
HIP Maternity may also be determined eligible for retroactive coverage prior to their application date.
Retroactive coverage for these members is provided through the fee-for-service (FFS) delivery system. The
eligibility verification system (EVS) will indicate Package A – Standard Plan as the member’s coverage
during the retroactive time period, with no enrolling MCE indicated. For dates of service on and after the
date eligibility was actually determined, the EVS will indicate the applicable benefit plan (such as
Package A – Standard Plan, Full Medicaid, or HIP Maternity) with a managed care assignment.
The exception to this policy is newborns whose mothers were enrolled with a managed care assignment on
the date of the child’s birth. In this case, the baby is assigned to the mother’s MCE, retroactively effective
to the date of birth. The mother’s and the baby’s coverage remains with the MCE during the baby’s
retroactive period. After an IHCP Member ID is assigned to the baby, providers may send claims for the
baby’s care to the mother’s MCE. Prior authorization (PA) for services may be required. Providers should
check with the MCE about PA before submitting claims or retroactive PA requests.
For all other members, services rendered during the retroactive eligibility period must be billed through the
FFS delivery system. Nonpharmacy claims should be submitted to DXC Technology; pharmacy claims
should be submitted to OptumRx. For dates of service after the managed care member’s retroactive
eligibility period must be submitted to the MCE with which the member is enrolled.
Limited Retroactive Eligibility for Hoosier Healthwise Package C Members
Members are given a conditional approval if they meet all Hoosier Healthwise Package C eligibility
requirements except for payment of the first premiums. Members become eligible for Hoosier Healthwise
Package C benefits on the first day of the month in which they applied; however, their enrollment does not
become effective until the required first month’s premium has been paid. For example, if an application
was filed in June and was approved June 15, and the applicant’s required first month’s premium was paid
in full for June, eligibility would begin on the first day of June.
Hoosier Healthwise Package C members are not eligible for coverage before the month in which they apply
for benefits. However, these members may be determined eligible for retroactive coverage under another
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category. If it is determined that a Package C member is retroactively eligible for another category,
retroactive coverage can begin up to 3 months prior to the date of application, and providers that have
rendered services to Package C members during the period of retroactive eligibility are bound by the
requirements described in the Provider Responsibilities for Retroactive Eligibility section.
During this limited retroactive period, member benefits will be covered through the FFS delivery system as
described in the previous section.
Provider Responsibilities for Retroactive Eligibility
Providers rendering services to members during a period of retroactive eligibility are bound by the
requirements that follow. This policy is mandatory and applies only in instances where the provider
was enrolled in the IHCP at the time the service was rendered.
When notified of a member’s retroactive eligibility, the provider must refund to the member any payments
made by the member for IHCP-covered services rendered during the member’s retroactive eligibility
period. If a provider’s office observes specific refund procedures, and those refund procedures apply to all
customers regardless of patient status, then refunds to IHCP members should be handled in the manner
dictated by normal office procedures. For example, an organization that routinely issues refunds at the end
of the month and mails the refunds by check can apply the same process to IHCP members.
The provider must then bill the IHCP for the covered service rendered during the member’s retroactive
eligibility period. Nonpharmacy claims should be submitted to DXC Technology; pharmacy claims should
be submitted to OptumRx.
If the service was rendered more than 180 days ago (or more than 1 year ago, for dates of service before
January 1, 2019) and is past the filing limit, the provider must submit a paper claim with appropriate
documentation requesting a filing limit waiver. The filing limit is waived if the claim is filed within 180
days of the date when the member was notified of his or her retroactive eligibility. Retroactive billing
procedures are discussed in the Claim Submission and Processing module.
If prior authorization (PA) is required for the covered service, such authorization may be requested
retroactively up to 180 days ago from the date the member was enrolled. The provider must indicate on the
PA request or with a cover letter that the reason for the untimely request was due to retroactive eligibility.
Authorization is determined solely on the basis of a medical necessity.
The following example illustrates retroactive enrollment:
An IHCP provider renders an IHCP-covered service on February 1, 2019, to a patient on a
private-pay basis. On April 1, 2019, the patient is enrolled in the IHCP retroactively to
November 1, 2018. The patient informs the provider and furnishes a member identification
card. The provider verifies program eligibility using one of the EVS options. After member
eligibility is verified, the provider refunds the full amount paid by the patient for the services
rendered on February 1, 2019. The provider bills the IHCP before the August 1, 2019, timely
filing limit (180 days after the date the member was retroactively enrolled). Providers must
return money paid by the IHCP member as soon as possible, according to normal office policy.
See the Third-Party Liability module when there is also a third-party carrier involved.
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Section 8: Member Appeals
If a member disagrees with any action that denies or delays member services or benefits – whether taken by
the Indiana Health Coverage Programs (IHCP), the county office of the Family and Social Services
Administration (FSSA) Division of Family Resources (DFR), or a contractor – the member can ask for a
hearing (pursuant to Code of Federal Regulations 42 CFR 431.200 et seq. and Indiana Administrative Code
405 IAC 1.1) by filing an appeal.
The process for appealing decisions about eligibility is listed on the notice applicants receive from the DFR.
Appeals must be submitted in writing. Guidance to members on how to submit an appeal is available from
the Member Appeals page on the IHCP member website at in.gov/medicaid/members.
Healthy Indiana Plan (HIP), Hoosier Care Connect, and Hoosier Healthwise members must contact their
managed care entity (MCE) and work through their grievance process. MCE members must first exhaust
their managed care remedies before submitting an appeal to the State.
All member requests for administrative hearings should include a letter stating the reason for appeal. The
letter must be signed and must include the member’s name and other important information, such as the
dates of the decision. The request should be sent to the following address:
Family and Social Service Administration
Office of Hearings and Appeals
402 W. Washington St., Room E034
Indianapolis, IN 46204
As an alternative, appeals regarding eligibility decisions can be sent to the local DFR office.
All appeals must be filed within 33 calendar days of the date the adverse decision was received or takes
effect, whichever is later. If the request is for a continuing service (for example, home healthcare), at least 10
days’ notice plus 3 days’ mailing time must be given before the effective date of the denial or modification,
except as permitted under 42 CFR 431.213 and 42 CFR 431.214. As required by statute, if the request for a
hearing is received before the effective date of the denial or modification of continuing services, services are
continued at the authorized level of the previous prior authorization (PA).
At the hearing, the member has the right to self-representation or to be represented by legal counsel, a friend,
a relative, or another spokesperson of the member’s choice. The member is given the opportunity to examine
the entire contents of his or her case file, and any and all materials used by the FSSA, county office, or the
contractor that made the adverse determination. Other IHCP and assistance benefits are not affected by a
request for a hearing.